A 70s M is bib ems for sob.  He has a history of chf and htn.  His hha called ems because he c.o. sob.  On arrival, his VS are hr 90, rr 22, bp 160 / 70, t 99.0, O2 sat is 90 on the ems nrb.  He is in moderate respiratory distress, and he is very obese and osa in appearance.  Lung sounds are clear, heart sounds are normal, no S3, you can’t see any veins in the neck due to obesity.  He has mild bilateral edema.  He has an extensive area of cellulitis in his RLQ abdominal wall.


He is lethargic, but if you poke him hard enough, he will open his eyes and respond.  However, he is unable to provide any history.


vbg = 7.13 / 140 / 110


What do we do next?

One Comment

  • SteveMcG


    lethargic, hypoxic, tachypneic, acidotic – not sure anybody would fault you for taking the definitive airway.

    Alternatively you could try HFNC (See FLORALI) or NIV.

    the obvious stuff, ekg, additional lab work. I am not sure what the vbg even says is that pco2? sodium?

    with the acidosis and cellulitis, ams, etc, You’ve also got SIRS/Sepsis although officially sirs is HR>90, so i’d start (at least consider) broad spectrum abx and sepsis protocol.

    Once immediately stabilized, I’d try to figure out the cellulitis and get more complete history. recent surgery at the site? nec fasc picture?

    CT may give a better picture if he is unable to give a good exam.

    doesn’t sound/look like his chf.

    admit micu/sicu if something in the belly.

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