Things that make you go hmmm.

[tniuqs]

How big is this patient?

The ventilator is set in a volume mode at 500 x 10 which only gives a 5 L MV. CO2 of 28?

What's the pt's total RR?

Anion gap?

SvO2?

CVP?

BP MAP? What's the goal for the MAP?

Yes great queries

What Mode would the patient be on as well?

Does one have the capability of doing an C (a-v) O2 diff?

hmm would be correct.

cheers

[chbare]

You can manage the ventilator how you see fit. You notice he was given doses between 500-750 mg/hour of diprivan in the OR. Currently, his diprivan drip is set at 50 mcg/kg/min. No analgesia has been given. No way to monitor CVP or SvO2.

Blood pressure remains unchanged.

Hbg: 11

Hct: 34

Take care,

chbare.

[VentMedic]

Anion gag was 22. Anything else beside lactate from MUDPILES?

Propofol related infusion syndrome is not unheard of especially with liver injury. Although bradycardia is typically found, tachycardia can also be present.

What Mode would the patient be on as well?

That is a standard volume mode settting. Hopefully it is Assist capable. PCV would not give a preset volume. I would hope no one uses SIMV (very old weaning mode but still found on some transport ventilators) on a sick patient.

Even the most sophisticated transport ventilators are still very limited in options. Thus, the person managing them must be knowledgable of the disease process and not treat the ventilator as a separate entity just to correct ABG numbers. Different suspected disease process require very different ventilator management. This patient is still doing most of the work on the ventilator to which his flow requirements have probably exceeded the ventilator's capabilities. The I:E ratio of !:2.2 as stated is probably the calculated for the rate or 10 since few if any transport vents can achieve adequate flow for that ratio with a RR total of 22 without deficit. Thus high WOB which will increase V/Q mismatching and deadspace with inadequate flow distribution.

[tniuqs]

Anion gag was 22. Anything else beside lactate from MUDPILES?

Propofol related infusion syndrome is not unheard of especially with liver injury.

That is a standard volume mode settting. Hopefully it is Assist capable. PCV would not give a preset volume. I would hope no one uses SIMV (very old weaning mode but still found on some transport ventilators) on a sick patient.

.

Agreed, AC is best in this situation because if Control is the only vent mode avaliable... this could be a serious complicating factor, just riding the vent with this minute volume and a CO2 of 28 ?? and with these gases strikes me as a bit odd.

With a CO2 of 28 expected PH should be 7.50 .... agreed again look to MUDPILES.

I am hoping that set MV vs actual MV at the time of ABGs were drawn and is not an issue here, some transport vents do not measure actual MV, just set.

Sooo What does CXRAY look like ?

Just a sidebar but the LTV 1000 would be my choice over any other transport vent with this rather complex picture, thats as if one had that option and I expect not .... just talking out loud is all.

cheers

[VentMedic]

LTV 1000 - The ventilator of choice for Superman. The LTV 1200 is even better with internal PEEP. PEEP wasn't mentioned here, maybe due to BP or not. 3 - 5 cmH2O usually won't affect too bad and will prevent some collapse.

Somebody on a Flight forum was talking about buying Uni Vent 73x for their interfacility transports. I cringe when I hear stuff like that from supposedly sophisticated teams. It is as bad as a Paramedic CCT showing up to the ICU with an ATV.

Apologies chbare, we drifted.

[p3medic]

Any chance we could get that 12ld and a basic metabolic panel? I like the idea of adding fentanyl.

[tniuqs]

LTV 1000 - The ventilator of choice for Superman.

Apologies chbare, we drifted.

1200 is for Wonder Women .... te he.

[chbare]

XII lead: Sinus tachycardia without ectopy or conduction abnormalities.

No apologies, good discussion.

Let's say you are able to rule out the typical MUDPILES as the cause of your anion gap acidosis. With the information available, where are things pointing? Somebody may have already mentioned the cause; however, I want to see what everybody else is thinking. What about the elevated CK and myoglobin in the urine? You can have your fentanyl and make any vent changes you deem appropriate. The patient is not currently on any PEEP.

Take care,

chbare.

[SANDMEDIC]

I prefer the Crossvent 3 or Crossvent 4.

This is one sick patient.

Adjust the vent settings and tell the pilot to fly faster.

In all reality this patient is fragile, I would load and go, and not play doctor.

This is one of those times I would be bouncing a lot of things off my flight nurse.

She has the ICU experience

Analgesic pain management with permissive hypotension.

Adjust vent setting as appropriate. Increase TV/ 5cm PEEP/

IABP monitoring en route if Swan-Ganz in place.

Fluid maintenance.

[chbare]

IABP and Swan Ganz are different. IABP is a counterpulsion balloon device placed in the aorta to augment output, coronary perfusion, and decrease myocardial work load. In some cases, you may use an invasive waveform and information to guide IABP setup and settings. Swan-Ganz is a catheter that typically sits in the pulmonary artery and is used to monitor various parameters and calculations.

My old flight gig have me using a CV4. Really liked the device, however, one big disadvantage is the fact that the CV4 cannot function without a compressed gas source. Currently, I have the Oxylog 2000. Not sure what to think as I have not used it on a patient. It is a very popular ventilator over here however. All of the ISAF hospitals appear use this device.

Apologies for the digression.

What do you think is going on? Is it even directly related to the trauma?

Take care,

chbare.