Page 75 - JSOM Summer 2025

• UOP is currently >1mL/kg/h, but the patient is still hypo- Time: +24 hours
thermic. Therefore he may still be experiencing cold diuresis. The patient still requires high FIO and continues to produce
2
Continue NS rate as above while monitoring output closely. significant frothy sputum, but his neurologic status is stable
• Give 50% dextrose (D50) IV push to due to borderline hy- and UOP has slowed. Medical staff are informed that evacua-
poglycemia and inability to tolerate nutrition. tion of the patient is still 24–36 hours away.
• Hold chemical venous thromboembolism (VTE) prophylaxis
due to unknown status of brain injury; if the patient is hem- The patient’s vital signs are: HR, 78; BP, 98/68mmHg; RR, 18
orrhaging, this intervention could have devastating results. (on ventilator); SpO 88%; temp: 37°C; RASS –1. Ventilator
2
• Hold gastrointestinal (GI) prophylaxis medication until settings: V-AC; TV, 420mL; FIO , 100%; RR, 18; PEEP, 15
2
normothermic. (increased again due worsening hypoxia from severe ARDS).
• Continue monitoring BP every 5 minutes while on vasopressors. There is persistent frothy sputum in ETT, requiring frequent
• Perform neurologic exams every 30 minutes. suction with in-line cannula. IV fluid and rate is room tem-
• Perform routine documentation detailing vital signs at min- perature LR at 125mL/h (changed due to normothermia). Cu-
imum every hour. Also document changes in status or exam. mulative IV fluid input is 5,875mL. Cumulative UOP is 1.9L
Caregivers should complete full patient documentation. yellow urine. Cumulative ETT output is 2.6L pink frothy spu-
• Avoid rolling/moving the patient until normothermic to tum. Cumulative NGT output is 800mL. No bowel movement
avoid triggering an arrhythmia. has occurred. Patient still localizing in all four extremities on
neurologic exam. Repeat lab values are: Na, 144; K, 4.6; Cl,
Time: +8 hours 104; CO , 20; Cr, 1.3; BUN, 30; Glu, 110; iCa, 1.2; Hg, 11.0;
2
Patient 2’s vital signs are: HR, 62bpm; BP, 100/68mmHg; RR, Hct, 36; VBG, 7.28; pO , 22; pCO , 49; lactate, 1.8.
2
2
18 (on ventilator); SpO , 86%; temperature, 35°C; RASS, –2.
2
Ventilator settings are: V-AC, TV, 420mL; FIO , 100%; RR Assessments indicate that the patient neurologic exam findings
2
18; PEEP, 10 (increased due to worsening hypoxia). Plateau are unchanged and he has been resuscitated appropriately. He
pressures (measured by briefly pausing the airflow at the end is diagnosed with severe ARDS.
of inspiration) are elevated (>30cmH O) There is persistent
2
frothy sputum present in ETT, requiring suctioning with in- Recommended interventions include the following:
line cannula. Three liters total of warmed NS is given, still
at the 125mL/h maintenance rate. Norepinephrine is discon- • The severity and associated mortality of ARDS is com-
tinued. UOP is 1.4L clear urine. The patient is still localizing monly estimated by determining the ratio of PaO /FIO .
41
2
2
pain in all four extremities. He is placed into a coaptation Arterial blood gas is not available on an LPD. However,
splint with sling per orthopedic surgeon recommendation over the ratio of peripheral oxygen saturation (SpO ) to FIO
2
2
teleconference. can help estimate PaO /FIO ratios to help determine se-
2
2
verity of ARDS (Table 4). SpO /FIO ratios of 235 and 315
2
2
Repeat lab values are: Na, 141; K, 5.0; Cl, 102; CO 19; Cr, correlate with PaO /FIO ratios of 200 and 300, respec-
2
2
2
1.2; BUN, 30; Glu, 110; iCa, 1.2; Hg, 11.2; Hct, 37; VBG: pH, tively. This patient currently has an SpO /FIO ratio of 88
42
2
2
7.30; pO , 30; pCO , 39; lactate, 2.7. which is significantly less than 235, and thus he likely has
2 2
severe ARDS based on the available information. In this
Recommended interventions include the following: austere maritime environment, proning, consideration of
dexamethasone, and euvolemia should all be considered.
43
• As the patient is continuing to over-diurese (>1mL/kg/h) Paralysis has previously been shown to have a mortality
and body temperature has almost normalized, maintenance benefit in ARDS, but a recent 2019 study showed no signif-
fluids can start to be slowed with continued close monitor- icant mortality benefit. Critical care and trauma surgery
44
ing of UOP and vital signs. telemedicine consultation is recommended to discuss the
• The patient’s ARDS is worsening as evidenced by the low following ARDS treatment strategies :
43
oxygen saturation as with worsening lung compliance (el- – Proning: 16/8 hour prone/supine ratio. This is time-
evated plateau pressures). Increase PEEP to 12; note: some and labor-intensive but has a demonstrated mortality
ventilators may not exceed PEEP of 15cmH O. Continue benefit. 45
2
close monitoring of ventilatory status with plateau pres- – IV dexamethasone 10mg twice daily for 5 days, fol-
sures every 4 hours and VBGs every 6 hours (if available); lowed by IV 10mg daily for 5 days. 46
monitor O saturations and ventilator alarms. – Continuous neuromuscular blockade (paralysis) may
2
• Continue to hold VTE and GI prophylactic medications. improve lung compliance, facilitate ventilator synchrony,
Continue to hold nutrition. and decrease metabolic demand. However, paralysis will
• Perform routine nursing care: significantly limit neurologic exams in patients with evi-
– Monitor vital signs and perform neurologic exams every dence of traumatic brain injury. If possible, discuss with
hour now that the patient has stabilized and the vaso- an intensivist or trauma/critical care surgeon via tele-
pressor has been discontinued. medicine consultation.
– Continue suctioning the ETT as necessary. – Continue to monitor hourly output; the patient is nor-
– Maintain an elevated head of bed between 30–60°. mothermic and can now be expected to produce normal
– Continue diligent documentation, including hourly in- UOP of 0.5mL/kg/h.
take and output (I&Os). – Initiate GI prophylaxis: IV Protonix (pantoprazole) if
– Perform oral care for an intubated patient every 4 hours. available; otherwise use oral ranitidine or omeprazole
– Once warmed, the patient should be rolled every 2 hours down NGT.
with padding placed over bony prominences to prevent – Enteral nutrition could be considered at this time. If
skin breakdown. a patient is being considered for possible initiation of
Drowning and Hypothermia on an Amphibious Warship | 73