A 76-year-old woman is hospitalized due to a fracture of her right proximal femur from an accidental nonsyncopal fall. Medical history is notable for breast cancer treated with a radical mastectomy 10 years ago, hypertension, and hyperlipidemia. She drinks a pint of vodka daily, but does not use tobacco or illicit drugs. The patient is started on thiamine and folic acid, and the next morning she undergoes orthopedic surgery for internal fixation of the right femur. She experiences mild agitation postoperatively, which is managed with as-needed, low-dose benzodiazepines. In addition, she is treated with low-molecular-weight heparin, opiates, and continued vitamin supplementation. On her third postoperative day, the nurse finds her agitated and in significant distress. The patient has an episode of nonbloody vomiting. On initial evaluation, she appears restless and confused but follows commands. Temperature is 36.7 C (98 F), blood pressure is 92/58 mm Hg, pulse is 122/min and regular, and respirations are 31/min. Pulse oximetry is 75% on room air and improves to 82% with supplemental oxygen by non-rebreather mask. Chest auscultation reveals no crackles or wheezes. Cardiac examination demonstrates tachycardia with a regular rhythm and normal S1 and S2. The abdomen is soft. Her pupils are equal and reactive to light, and she is moving all extremities.
Which of the following is the most appropriate next step in management of this patient?

Question

A 76-year-old woman is hospitalized due to a fracture of her right proximal femur from an accidental nonsyncopal fall.  Medical history is notable for breast cancer treated with a radical mastectomy 10 years ago, hypertension, and hyperlipidemia.  She drinks a pint of vodka daily, but does not use tobacco or illicit drugs.  The patient is started on thiamine and folic acid, and the next morning she undergoes orthopedic surgery for internal fixation of the right femur.  She experiences mild agitation postoperatively, which is managed with as-needed, low-dose benzodiazepines.  In addition, she is treated with low-molecular-weight heparin, opiates, and continued vitamin supplementation.  On her third postoperative day, the nurse finds her agitated and in significant distress.  The patient has an episode of nonbloody vomiting.  On initial evaluation, she appears restless and confused but follows commands.  Temperature is 36.7 C (98 F), blood pressure is 92/58 mm Hg, pulse is 122/min and regular, and respirations are 31/min.  Pulse oximetry is 75% on room air and improves to 82% with supplemental oxygen by non-rebreather mask.  Chest auscultation reveals no crackles or wheezes.  Cardiac examination demonstrates tachycardia with a regular rhythm and normal S1 and S2.  The abdomen is soft.  Her pupils are equal and reactive to light, and she is moving all extremities. 
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This postoperative patient with tachycardia, tachypnea, and persistent hypoxemia following initiation of supplemental oxygen is in acute respiratory failure; she requires urgent stabilization, which is best accomplished with endotracheal rapid-sequence intubation (RSI). RSI makes use of a rapidly acting sedative (eg, etomidate, propofol, midazolam) and a paralytic agent (eg, succinylcholine, rocuronium) to facilitate emergent intubation while preventing aspiration. Once intubated and stabilized, the cause of this patient's acute respiratory failure can be diagnosed and managed. (Choices A and B) Testing for the possible etiologies of this patient's respiratory failure (eg, myocardial infarction, acute pulmonary embolism) cannot be performed until she has been intubated and stabilized. Excessive delay in endotracheal intubation and initiation of ventilatory support is likely to lead to cardiac arrest from respiratory failure. (Choice D) Benzodiazepines decrease respiratory drive and should be avoided in patients with respiratory failure, with the exception of short-acting benzodiazepines (eg, midazolam) for sedation during RSI. In addition, high-flow supplemental oxygen is unlikely to provide significantly more benefit to this patient than the non-rebreather mask is already providing. Ventilatory support with mechanical ventilation is needed. (Choice E) Noninvasive positive-pressure ventilation (eg, continuous positive airway pressure, bilevel positive airway pressure) uses a face or nasal mask to administer pressurized air into the lungs. It is often useful for ventilatory support in patients with acute respiratory failure due to chronic obstructive pulmonary disease or heart failure; however, it does not protect the airway and is contraindicated in this patient with impaired consciousness and risk of aspiration. Educational objective: Critically ill patients who are unstable with significant hypoxemia require rapid-sequence intubation for ventilatory support and/or airway protection. After initial stabilization of the airway, patients may be appropriately assessed for the underlying etiology of acute respiratory failure. References: Airway management of the critically ill patient: rapid-sequence intubation. (http://www.ncbi.nlm.nih.gov/pubmed/15821222)

A 76-Year-Old Woman Is Hospitalized Due to a Fracture of Her