DrVirgo
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12. An 8 y/o boy is brought to the ER complaining of difficulty breathing. His mother states he has asthma and regularly inhales beta-agonists adn corticosteroids. She also reports he had an upper respiratory infection for the past three days. On examination, wheezing is present throughtout both lung fields, intercostal and supraclavicular retractions and nasal flaring are absent. A peak expiratory flow rate is 80l/min. Arterial blood gas results in room air are as follows:
pH: 7.42
PaCO2: 42 mmHg
PaO2: 85 mmHg
Which of the following is the most appropriate next step in management?
A. Administer intravenous ampicillin
B. Administer inhaled cromolyn
C. Order an immediate chest x-ray
D. Prepare to intubate and ventilate mechanically
E. Reassure the mother since the blood gas is normal
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| DrVirgo
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No.
Correct Answer is D. Prepare to intubate adn ventilate mechanically.
PsO2 is 85, so there is decreased O2!
Anything else to add?
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| Guptashutosh
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ans is C , cxr... possibility of pneumonia is strong as chil is also on steroids so inflamatory reactions and thus clinica ll signs may be less..
h/o uri support the ans..
no need for ventilation as per abg
cromolyn is effective for prophylaxis only not in acute situations
reassurence can be dangerous
iv ampicillin is to be given after c/s
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| Aashi
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Absence of any lower respiratory s/s makes asking for cxray unncessary..the hx is negative for cough,fever or chills..Cray is not asked in asthma exhaberration..we go directly to meds here...
Edited by Aashi on 12/20/06 - 10:11 AM
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| DrVirgo
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For sure the answer is D... Thats the given right answer.
What about the decreased PaO2? Meds are not a choice. And CXR is ALWAYS the wrong answer in Asthma because it won't show anything.
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| mazinger
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The right asnwer is D, its because the patient is getting tired he is no longer hyperventilating, he is still in respiratory distress, he also has hypoxemia which reflects his ventilation is still inefficient.. Asthma patients start hyperventilating decreasing the pCO2 (pCO2 is mainly determined by the metabolic production of CO2 and the ventilatory rate, since the met rate is constant then it means in this case is going to be affected ONLY by the alveolar ventilation rate), as they get tired they return to normal pCO2 and finally to high pCO2.. Be aware that the patient remains hypoxic during the whole attack..
Regards 
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| alpha12
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D is the answer
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| aml
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D MOST LIKELY FROM GIVEN CHOICES
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| desijwl
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Patient is crashing.....normal PCO2 levels...in an asthmatic is a warning sign! Asthmatics usually have a low CO2 due to hyperventilation...this patient is tiring out...and accumulating CO2!
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| ssrpk
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i wud have agreed with aashi! if i had'nt considered the value of peak expiratory flow rate [80L/min].....its wayyyyyy low!
should be above 200L/min, below 100L/min is evidence of life threatening disease!
the rest of the explanations are perfect! pateint is indeed getting too tired as evidenced by rising PCO2 levels!
answer is D- mechanical ventilation is truely required here!
good luck
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| anjushree
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CMDT writes PEF LESS THAN 200 L/MIN INDICATES SEVERE AIRFLOW OBS
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| prathapdoctor
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the correct answer is D only, in any patient during acute attack of asthma,if PCO2 levels are normal or greater than normal,it indicates severe respiratory distress and is an indication for mechanical ventilation.
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| s2ckdeficient
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answer is D------------- cuz even if the patient had a pneumonia, me knowing that is not going to keep the kid alive through the night.
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