4-25
Objective: Signs
Using Basic Tools: Vital signs: Fever > 101.5°F, RR > 18, HR > 100, BP < 110/60
Inspection: Toxic and unstable, cyanotic (blue/gray/purple skin discoloration), use of accessory muscles in
impending respiratory failure.
Respiratory System: Normal in Phase I and rales in Phase II.
Neuro exam : Agitation, followed later by lethargy and obtundation.
Using Advanced Tools: Pulse Oximeter: Oxygen saturation < 90% and not responsive to oxygen therapy;
CXR: Normal at 2- 24 hours, then diffuse, fluffy infiltrates & pulmonary edema at 48- 96 hours.
Assessment:
Differential Diagnosis
Other causes of Pulmonary Edema - drowning (typical history); drug overdose (history of exposure and
mental status changes); non-septic shock (see Shock chapter and eliminate causes of shock); congestive
heart failure (peripheral edema, orthopnea and other findings—see Cardiac: CHF).
Diffuse infectious pneumonia (see Respiratory: Pneumonia).
Plan:
Treatment
Primary:
- Evacuate for ICU and ventilator support. If evacuation is not possible, skip steps below, make patient
comfortable and treat expectantly. - Pending evacuation and en route, administer oxygen– start with low flow 2 L/min and increase as needed.
- Treat the underlying specific etiology, if recognized.
- Administer fluid and blood products sparingly to minimize severity of pulmonary edema.
- Administer broad-spectrum antibiotics (see Respiratory: Pneumonia).
Patient Education
Activity: Limit activity.
Prevention: Suspect this complication with severe injuries and evacuate early.
Follow-up Actions
Evacuation/Consultation Criteria: Urgently evacuate patients with severe injuries, particularly those who
are elderly, very young, have underlying chronic diseases or are immunocompromised. Consult pulmonologist
or internist.
Respiratory: Apnea
COL Warren Whitlock, MC, USAIntroduction: Apnea is the cessation of breathing for >10 seconds at a rate of >20 times an hour, and it
occurs most commonly during sleep. Apneic episodes may occur up to 5 times per minute in normal adults,
usually during rapid eye-movement (REM) sleep. Apnea is also known as “obstructive sleep apnea” or as
“Pickwickian Syndrome” in the obese. The obstruction is usually due to enlarged pharyngeal tissues in the
obese, inamed tonsils, low-hanging soft palate or uvula, or craniofacial abnormalities that narrow or close
the airway. Relaxation of pharyngeal and palatal muscles from alcohol, sedatives, muscle relaxants or other
CNS depressants can contribute to snoring and airway closure at night. Apnea is associated with hypoxia and
frequent nocturnal arousals (60-100 per hour), contributing to excessive daytime sleepiness. Apnea generally
does not cause shortness of breath unlike other conditions associated with a narrow upper airway, such as
epiglottis. Hypertension is the most common medical condition accompanying sleep apnea. Underlying lung
disease (COPD) worsens apnea. Risk Factors: Obesity, nasal obstruction (due to polyps, deviated septum, old
trauma), hypothyroidism, upper airway narrowing, sedative drugs and alcohol.