WIDI - C19) Worsening hypoxia after intubation

C19) Worsening hypoxia after intubation

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with hypoxia.
Review the DDx considerations in a patient with hypoxia.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with hypoxia.

History

A 25-year-old male presented following a burn injury with inhalational injury. He was intubated for airway protection and subsequently developed worsening hypoxia.

Physical Exam

BP: 119/72, HR 125, RR 21, Temp 37.2C, O2 saturation 82%.

Provisional Diagnosis

Select the Dx you believe is most appropriate

ARDS

Malpositioned endotracheal tube

Worsening hypoxia following endotracheal tube (ETT) placement is likely secondary to a malpositioned ETT. ARDS usually develops five days following severe burn injuries.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

Emergent workup should take place considering the acute onset hypoxia.

First Imaging Study

What is the first imaging study you will order?

Chest x-ray

Chest CT

Chest-xray is readily available in the trauma bay, can determine ETT placement, and can assess for acute lung pathologies.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Chest x-ray

What best describes the findings on the Chest X-ray?

Malpositioned ETT

Lobar collapse

Low lung volume

A and B

All of the above

The endotracheal tube is malpositioned with its tip entering the right main bronchus, 3cm past the carina. The left lung as a result is underinflated secondary to decreased ventilation of the left main bronchus. The right upper lobe is collapsed secondary to the decreased ventilation of the right upper lobe bronchus.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

None

Chest CT

No further imaging is required.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Malpositioned endotracheal tube requiring advancement by 2cm.

Malpositioned endotracheal tube requiring retraction by 3cm.

Malpositioned endotracheal tube requiring retraction by 6cm.

The endotracheal tube should be 3cm above the carina and therefore should be retracted by 6cm.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

This patient with inhalational burn injury experienced respiratory distress secondary to a malpositioned endotracheal tube.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a patient with inhalational burn injury who became increasingly hypoxic following intubation. Chest X-ray revealed a malpositioned ETT, which we will retract by 6cm.

Lessons Learned:
- A chest X-ray following intubation can assess for proper positioning of an endotracheal tube (in addition to directly visualizing the trachea during intubation, using exhaled CO2 or colorimetry, and confirming breath sounds).

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