EM Forum Case #116 "The Blue Nurse"
by Charlene Babcock Irvin, MD, FACEP  

I’m called to the resuscitation suite for a medical ‘code’. As I walk into the room, I see a middle aged cyanotic female, in obvious respiratory distress, awake and talking to the nurse with one word sentences.

Looking to the nurse, I’m glad she quickly summarizes what she knows: A 42 y/o female with cough, fever and respiratory distress. She got sick yesterday, and now can’t breathe. Her husband brought her in. Her room air sat is only 72%.

Most of my history is from her husband. She became acutely ill yesterday, and has progressively been getting worse. He wanted to bring her yesterday to the ED, but she refused. She is a nurse and thought she might be able to manage this at home. She thought it was a virus, but now continues to get worse so finally she agreed to come to the ED.

ROS: No vomiting, diarrhea, rashes. She has had a decreased appetite, and felt hot with chills on and off since yesterday. She has been coughing up green sputum, and complains of chest pain when she coughs.
PMH: Negative, healthy with no medical problems. G2P2
Allergies: None
Medications: Ibuprofen prn
SH: No smoking. She has not been around patients who have had an unusual illness (according to her husband). No unusual exposures.
FH: Neg
PE: WDWN female, cyanotic as she is placed on oxygen, in obvious respiratory distress.
VS: HR-140, RR=32, BP=140/85, Temp=101F, Sat (now on 100%NRB = 88)
HEENT: Unremarkable, no JVD
Heart: RR tachy, no murmurs
Lungs: Rales bilaterally, no rhonchi
Abd: Scaphoid, non-tender
Ext: No rashes
Neurologic: non-focal
CXR: Non-cardiogenic pulmonary edema with multiple patchy infiltrates
WBC: 26K with 30% Bandemia
Lactate =4.2

Questions:

1. Should you intubate?

2. What is ECMO?

3. How is Adult Respiratory Distress Syndrome (ARDS) defined? What should your ventilator settings be?

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