CSTARS Scenario 4

Moderate ARDS with Tension Pneumothorax

Description

A 25 year-old soldier was injured following an IED detonation while dismounted. He suffered a traumatic amputation of the right lower extremity below the knee, multiple puncture wounds from fragments in the left lower extremity and lost consciousness at the scene. A tourniquet was applied and the hemorrhage mitigated. Both eardrums were ruptured and his GCS was 12. He underwent a massive transfusion, received 10 units of whole blood, crystalloid infusions and platelets. In the operating room primary control of hemorrhage was achieved and the lower extremity amputation addressed using standard techniques. The patient arrived from the operating room on mechanical ventilation. He was sedated and is not currently triggering the ventilator. The patient is 5'9" tall, weighs 170 lbs and has no known comorbidities or allergies.

Figure 1. Chest radiograph demonstrates subcutaneous air and small pneumomediastinum. There is no pneumothorax.

Segment Validation

Segment 1

Learning Objectives:

  • Assess baseline status
  • Recognize moderate ARDS

Recommended Actions:

  • None


Ventilator settings are (VT Target = 6.9 mL/kg (ideal)):

Mode VT (L) PIP (cmH2O) Flow (L/min) I:E TI (s) RR (bpm) PEEP (cmH2O) FiO2
VC-CMV 0.488 NA 52 NA 0.6 24 5 0.4
Table 1. Data request validation results for Segment 1.
Property Name Validation Engine Value Percent Error Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 488 484 0.735%   VT (measured)
InspiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [17] 12.4 2.97%   Rinsp for moderate ARDS
ExpiratoryRespiratoryResistance(cmH2O_s/L) EqualTo 12 [17] 12.4 3.05%   Rexp for moderate ARDS
RespiratoryCompliance(mL/cmH2O) EqualTo 40 [305] 41.0 2.55%   C requested by SME for moderate ARDS
PhysiologicDeadSpaceTidalVolumeRatio EqualTo 0.57 [230] 0.553 2.97%   VD/VT for moderate ARDS
ClinicalShuntFraction [0.300,0.500] [222] 0.370 0.00%   QS/QT for moderate ARDS (determined from blood gas values)
HorowitzIndex(mmHg) [100,200] [115] 142 0.00%   PaO2/FiO2


Figure 2. Vitals and ventilator monitors for Segment 1.


Table 2. Data requests for Segment 1.
Property Name Engine Value
Patient-Height(in) 69.0
Patient-IdealBodyWeight(kg) 70.7
InspiratoryRespiratoryResistance(cmH2O_s/L) 12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L) 12.4
RespiratoryCompliance(mL/cmH2O) 41.0
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.468
ClinicalShuntFraction 0.370
MechanicalVentilator-TidalVolume(L) 0.484
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 56.8
Aorta-CarbonDioxide-PartialPressure(mmHg) 46.8
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.901
HorowitzIndex(mmHg) 142
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.280
MechanicalVentilator-RespirationRate(1/min) 24.0
MechanicalVentilator-MeanAirwayPressure(cmH2O) 9.01
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 27.3
MechanicalVentilator-PlateauPressure(cmH2O) 17.3
HeartRate(1/min) 102
SystolicArterialPressure(mmHg) 112
DiastolicArterialPressure(mmHg) 79.7
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 11.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 12.4
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 12.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 40.2
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 21.7
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 32.7
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 267
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.484
MechanicalVentilator-InspiratoryExpiratoryRatio 0.316
MechanicalVentilator-InspiratoryTidalVolume(L) 0.484
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.789
MechanicalVentilator-LeakFraction 0.00
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.263
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.26
PhysiologicDeadSpaceTidalVolumeRatio 0.553
ShuntFraction 0.377
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelCompliance(mL/cmH2O) 49.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.28
EndTidalCarbonDioxidePressure(mmHg) 35.6
PhysiologicDeadSpace(mL) 274
AlveolarArterialGradient(mmHg) 202
AlveolarDeadSpace(mL) 132
AnatomicDeadSpace(mL) 141
ChestWallCompliance(L/cmH2O) 0.121
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0643
VentilationPerfusionRatio 2.87
HeartStrokeVolume(mL) 63.2
HeartEjectionFraction 0.498
BloodVolume(L) 5.57
MeanArterialPressure(mmHg) 96.3
PulsePressure(mmHg) 32.3
CardiacOutput(L/min) 6.45
CarbonDioxideSaturation 0.246
RespiratoryExchangeRatio 0.815
SystemicVascularResistance(mmHg_s/mL) 0.852
OxygenConsumptionRate(mL/min) 253
CarbonDioxideProductionRate(mL/min) 207
Patient-AlveoliSurfaceArea(m^2) 12.8
Patient-ExpiratoryReserveVolume(L) 0.820
Patient-FunctionalResidualCapacity(L) 1.21
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.39
Patient-ResidualVolume(L) 0.393
Patient-TidalVolumeBaseline(L) 0.541
Patient-TotalLungCapacity(L) 4.14
Patient-VitalCapacity(L) 3.75

Segment 2

The patient is loaded in the aircraft for transport to level III care. Twenty minutes into the transport SpO2 falls and PIP and Pplat are increased. The patient remains sedated and is not triggering the ventilator. Learning Objectives:

  • Recognize and treat pneumothorax

Recommended Actions:

  • Increase in Pplat with same tidal volume indicates decreased compliance
  • This observation along with diminished breath sounds and hyper-resonance with percussion on one side indicate pneumothorax
  • Recommend needle decompression


Table 3. Data request validation results for Segment 2.
Property Name Validation Engine Value Percent Error Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 488 485 0.573%   VT (measured)
RespiratoryCompliance(mL/cmH2O) LessThan Segment1 (41.0) [305] 21.2   -48.4% C
SystolicArterialPressure(mmHg) LessThan Segment1 (112) [305] 71.6   -36.1% BP
DiastolicArterialPressure(mmHg) LessThan Segment1 (79.7) [305] 57.2   -28.3% BP
Aorta-Oxygen-PartialPressure(mmHg) LessThan Segment1 (56.8) [186] 37.4   -34.3% PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) GreaterThan Segment1 (27.3) [305] 33.0   20.8% PIP
MechanicalVentilator-PlateauPressure(cmH2O) GreaterThan Segment1 (17.3) [305] 28.7   65.4% Pplat


Figure 3. Vitals and ventilator monitors for Segment 2.


Table 4. Data requests for Segment 2.
Property Name Engine Value
Patient-Height(in) 69.0
Patient-IdealBodyWeight(kg) 70.7
InspiratoryRespiratoryResistance(cmH2O_s/L) 15.9
ExpiratoryRespiratoryResistance(cmH2O_s/L) 13.7
RespiratoryCompliance(mL/cmH2O) 21.2
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.544
ClinicalShuntFraction 0.471
MechanicalVentilator-TidalVolume(L) 0.485
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 37.4
Aorta-CarbonDioxide-PartialPressure(mmHg) 47.0
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.743
HorowitzIndex(mmHg) 93.5
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.0411
MechanicalVentilator-RespirationRate(1/min) 24.0
MechanicalVentilator-MeanAirwayPressure(cmH2O) 10.5
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 33.0
MechanicalVentilator-PlateauPressure(cmH2O) 28.7
HeartRate(1/min) 146
SystolicArterialPressure(mmHg) 71.6
DiastolicArterialPressure(mmHg) 57.2
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 11.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 15.9
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 13.6
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 20.5
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 17.4
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 26.3
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 279
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.485
MechanicalVentilator-InspiratoryExpiratoryRatio 0.316
MechanicalVentilator-InspiratoryTidalVolume(L) 0.485
MechanicalVentilator-PeakExpiratoryFlow(L/s) 1.13
MechanicalVentilator-LeakFraction 0.000988
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.0264
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.03
PhysiologicDeadSpaceTidalVolumeRatio 0.553
ShuntFraction 0.442
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelCompliance(mL/cmH2O) 40.2
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.04
EndTidalCarbonDioxidePressure(mmHg) 28.2
PhysiologicDeadSpace(mL) 274
AlveolarArterialGradient(mmHg) 200
AlveolarDeadSpace(mL) 132
AnatomicDeadSpace(mL) 141
ChestWallCompliance(L/cmH2O) 0.0666
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0399
VentilationPerfusionRatio 5.62
HeartStrokeVolume(mL) 26.3
HeartEjectionFraction 0.361
BloodVolume(L) 5.60
MeanArterialPressure(mmHg) 64.2
PulsePressure(mmHg) 14.4
CardiacOutput(L/min) 3.84
CarbonDioxideSaturation 0.265
RespiratoryExchangeRatio 0.779
SystemicVascularResistance(mmHg_s/mL) 0.866
OxygenConsumptionRate(mL/min) 263
CarbonDioxideProductionRate(mL/min) 204
Patient-AlveoliSurfaceArea(m^2) 12.8
Patient-ExpiratoryReserveVolume(L) 0.820
Patient-FunctionalResidualCapacity(L) 1.21
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.39
Patient-ResidualVolume(L) 0.393
Patient-TidalVolumeBaseline(L) 0.541
Patient-TotalLungCapacity(L) 4.14
Patient-VitalCapacity(L) 3.75

Segment 3

Needle decompression procedure performed. Learning Objectives:

  • Recognize resolution of pneumothorax.

Recommended Actions:

  • SpO2, breath sounds, plateau pressure indicate pneumothorax resolved
  • Increase FiO2 to get SpO2 88-95%


Table 5. Data request validation results for Segment 3.
Property Name Validation Engine Value Percent Error Percent Change Notes
MechanicalVentilator-TidalVolume(mL) EqualTo 488 485 0.681%   VT (measured)
RespiratoryCompliance(mL/cmH2O) GreaterThan Segment2 (21.2) [305] 40.1   89.2% C
SystolicArterialPressure(mmHg) GreaterThan Segment2 (71.6) [305] 108   50.5% BP
DiastolicArterialPressure(mmHg) GreaterThan Segment2 (57.2) [305] 83.3   45.8% BP
Aorta-Oxygen-PartialPressure(mmHg) GreaterThan Segment2 (37.4) [186] 54.5   45.8% PaO2
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) LessThan Segment2 (33.0) [305] 26.8   -18.7% PIP
MechanicalVentilator-PlateauPressure(cmH2O) LessThan Segment2 (28.7) [305] 17.4   -39.4% Pplat


Figure 4. Vitals and ventilator monitors for Segment 3.


Table 6. Data requests for Segment 3.
Property Name Engine Value
Patient-Height(in) 69.0
Patient-IdealBodyWeight(kg) 70.7
InspiratoryRespiratoryResistance(cmH2O_s/L) 12.4
ExpiratoryRespiratoryResistance(cmH2O_s/L) 12.4
RespiratoryCompliance(mL/cmH2O) 40.1
ClinicalPhysiologicDeadSpaceTidalVolumeRatio 0.490
ClinicalShuntFraction 0.370
MechanicalVentilator-TidalVolume(L) 0.485
BloodPH 7.35
Aorta-Oxygen-PartialPressure(mmHg) 54.5
Aorta-CarbonDioxide-PartialPressure(mmHg) 46.7
Aorta-Bicarbonate-Molarity(mEq/L) 26.2
OxygenSaturation 0.889
HorowitzIndex(mmHg) 136
IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.201
MechanicalVentilator-RespirationRate(1/min) 24.0
MechanicalVentilator-MeanAirwayPressure(cmH2O) 8.94
MechanicalVentilator-PeakInspiratoryPressure(cmH2O) 26.8
MechanicalVentilator-PlateauPressure(cmH2O) 17.4
HeartRate(1/min) 127
SystolicArterialPressure(mmHg) 108
DiastolicArterialPressure(mmHg) 83.3
MechanicalVentilator-TotalPulmonaryVentilation(L/min) 11.6
MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) 12.6
MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) 12.4
MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) 40.0
MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) 22.2
MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) 30.9
MechanicalVentilator-EndTidalOxygenPressure(mmHg) 271
MechanicalVentilator-ExpiratoryTidalVolume(L) 0.456
MechanicalVentilator-InspiratoryExpiratoryRatio 0.316
MechanicalVentilator-InspiratoryTidalVolume(L) 0.485
MechanicalVentilator-PeakExpiratoryFlow(L/s) 0.753
MechanicalVentilator-LeakFraction 0.0586
MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) 0.265
MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) 5.26
PhysiologicDeadSpaceTidalVolumeRatio 0.553
ShuntFraction 0.365
TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) 12.4
TotalRespiratoryModelCompliance(mL/cmH2O) 47.7
ExtrinsicPositiveEndExpiratoryPressure(cmH2O) 5.00
TotalPositiveEndExpiratoryPressure(cmH2O) 5.20
EndTidalCarbonDioxidePressure(mmHg) 34.2
PhysiologicDeadSpace(mL) 274
AlveolarArterialGradient(mmHg) 202
AlveolarDeadSpace(mL) 132
AnatomicDeadSpace(mL) 141
ChestWallCompliance(L/cmH2O) 0.117
FractionOfInspiredOxygen 0.400
LungCompliance(L/cmH2O) 0.0643
VentilationPerfusionRatio 3.10
HeartStrokeVolume(mL) 46.4
HeartEjectionFraction 0.427
BloodVolume(L) 5.63
MeanArterialPressure(mmHg) 95.6
PulsePressure(mmHg) 24.4
CardiacOutput(L/min) 5.88
CarbonDioxideSaturation 0.240
RespiratoryExchangeRatio 0.810
SystemicVascularResistance(mmHg_s/mL) 0.917
OxygenConsumptionRate(mL/min) 247
CarbonDioxideProductionRate(mL/min) 200
Patient-AlveoliSurfaceArea(m^2) 12.8
Patient-ExpiratoryReserveVolume(L) 0.820
Patient-FunctionalResidualCapacity(L) 1.21
Patient-InspiratoryCapacity(L) 2.93
Patient-InspiratoryReserveVolume(L) 2.39
Patient-ResidualVolume(L) 0.393
Patient-TidalVolumeBaseline(L) 0.541
Patient-TotalLungCapacity(L) 4.14
Patient-VitalCapacity(L) 3.75

Scenario Output Plots


Figure 5. Select outputs from the scenario.


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