Board Review

Never Bored Review 9/9/14

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Made up Case:

70 yo ESRD (LUE fistua, MWF, last yesterday), HTN, DM, severe COPD presents peds struck by semi:

Airway, Breathing, Circulation initially intact, IV/O2/Monitor placed

102, 150/60, 28, 93% on RA

Secondary survey neg except for pan-right sided pain.

CXR/pelvis X-Ray unremarkable.

Pan-Scan (come on, 70 and hit by a semi, who wouldn’t pan-scan him?) shows entire right lung white out! Rest of scan is unremarkable

Diagnosis?
Pneumonia…Kidding. It’s a Pulmonary Contusion!

 

What's the white stuff?
edema and hemorrhage (but no large lung lacerations)

 

What do you NOT want to do?
Give fluids to a cardiovascularly stable old man with a pulmonary contusion. Fluids can actually worsen the disease including causing edema to the other, uninjured lung! There are probably many other things you do not want to do, sorry for the “read my mind” question.

 

Dispo/Treatment?
1. Maintain Oxygenation, which, in a 70 year old with an entire lung out and severe COPD…very likely will require intubation. Very high risk for ARDS.

2. In the meantime, incentive spirometer and pain control to prevent atelectasis.

3. Admit to surgery, likely SICU.

 

By Dr. Andrew Grock and Dr. Sally Bogoch

 

References

Tintinalli’s 7th ed.chpt 258

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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andygrock

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