En Route Care Scenario 4
Moderate ARDS with Tension Pneumothorax
Description
A 25 year-old patient was injured following an explosive detonation. 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. @subsection autotoc_md746 Segment Validation @subsubsection autotoc_md747 Segment 1 Learning Objectives: - Assess baseline status - Recognize moderate ARDS Recommended Actions: - None <br> Ventilator settings are (VT Target = 6.9 mL/kg (ideal)): <table class="markdownTable"> <tr class="markdownTableHead"> <th class="markdownTableHeadNone"> Mode
VT (L)
PIP (cmH2O)
Flow (L/min)
I:E
TI (s)
RR (bpm)
PEEP (cmH2O)
FiO2
VC-AC
0.488
NA
52
NA
0.6
24
5
0.4
Ventilator alarm settings are:
- High PIP = 37 cmH2O (~10 cmH2O above the initial value or a max of 40 cmH2O)
- Low MVe = 8.7 L/min (~25% below the initial value)
- Low VT = 360 mL (~25% below the initial value)
- High RR = 34 bpm (~10 bpm above the initial value or a max of 40 bpm)
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| MechanicalVentilator-TidalVolume(mL) | EqualTo 488 | 484 | -0.73% | VT (measured) | |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [18] | 12.4 | 3.11% | Rinsp for moderate ARDS | |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | EqualTo 12 [18] | 12.4 | 3.12% | Rexp for moderate ARDS | |
| RespiratoryCompliance(mL/cmH2O) | EqualTo 40 [316] | 41.1 | 2.63% | C requested by SME for moderate ARDS | |
| PhysiologicDeadSpaceTidalVolumeRatio | EqualTo 0.57 [238] | 0.553 | -2.92% | VD/VT for moderate ARDS | |
| ClinicalShuntFraction | [0.300,0.500] [229] | 0.377 | 0.00% | QS/QT for moderate ARDS (determined from blood gas values) | |
| HorowitzIndex(mmHg) | [100,200] [119] | 138 | 0.00% | PaO2/FiO2 |
| 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) | 41.1 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.407 |
| ClinicalShuntFraction | 0.377 |
| MechanicalVentilator-TidalVolume(L) | 0.484 |
| BloodPH | 7.35 |
| Aorta-Oxygen-PartialPressure(mmHg) | 55.0 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 43.8 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.2 |
| OxygenSaturation | 0.897 |
| HorowitzIndex(mmHg) | 138 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.281 |
| MechanicalVentilator-RespirationRate(1/min) | 24.0 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 9.01 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 27.3 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 17.3 |
| HeartRate(1/min) | 122 |
| SystolicArterialPressure(mmHg) | 110 |
| DiastolicArterialPressure(mmHg) | 83.3 |
| 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) | 32.3 |
| 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) | 0.264 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 5.26 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.381 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 48.8 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 5.28 |
| EndTidalCarbonDioxidePressure(mmHg) | 35.3 |
| PhysiologicDeadSpace(mL) | 274 |
| AlveolarArterialGradient(mmHg) | 208 |
| AlveolarDeadSpace(mL) | 132 |
| AnatomicDeadSpace(mL) | 141 |
| ChestWallCompliance(L/cmH2O) | 0.121 |
| FractionOfInspiredOxygen | 0.399 |
| LungCompliance(L/cmH2O) | 0.0643 |
| VentilationPerfusionRatio | 0.811 |
| HeartStrokeVolume(mL) | 51.6 |
| HeartEjectionFraction | 0.446 |
| BloodVolume(L) | 5.51 |
| MeanArterialPressure(mmHg) | 97.2 |
| PulsePressure(mmHg) | 26.9 |
| CardiacOutput(L/min) | 6.32 |
| CarbonDioxideSaturation | 0.0922 |
| RespiratoryExchangeRatio | 0.798 |
| SystemicVascularResistance(mmHg_s/mL) | 0.878 |
| OxygenConsumptionRate(mL/min) | 249 |
| CarbonDioxideProductionRate(mL/min) | 199 |
| Patient-AlveoliSurfaceArea(m^2) | 12.8 |
| Patient-ExpiratoryReserveVolume(L) | 0.820 |
| Patient-FunctionalResidualCapacity(L) | 1.21 |
| Patient-InspiratoryCapacity(L) | 2.93 |
| Patient-InspiratoryReserveVolume(L) | 2.41 |
| Patient-ResidualVolume(L) | 0.393 |
| Patient-TidalVolumeBaseline(L) | 0.516 |
| Patient-TotalLungCapacity(L) | 4.14 |
| Patient-VitalCapacity(L) | 3.75 |
Segment 2
The patient is loaded in the aircraft for transport to trauma center 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
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| MechanicalVentilator-TidalVolume(mL) | EqualTo 488 | 451 | -7.67% | VT (measured) | |
| RespiratoryCompliance(mL/cmH2O) | LessThan Segment1 (41.1) [316] | 21.1 | -48.54% | C | |
| SystolicArterialPressure(mmHg) | LessThan Segment1 (110) [316] | 86.1 | -21.92% | BP | |
| DiastolicArterialPressure(mmHg) | LessThan Segment1 (83.3) [316] | 76.3 | -8.46% | BP | |
| Aorta-Oxygen-PartialPressure(mmHg) | LessThan Segment1 (55.0) [193] | 24.6 | -55.28% | PaO2 | |
| OxygenSaturation | LessThan Segment1 (0.897) [316] [320] | 0.482 | -46.27% | SpO2 | |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | GreaterThan Segment1 (27.3) [316] | 37.6 | 37.83% | PIP | |
| MechanicalVentilator-PlateauPressure(cmH2O) | GreaterThan Segment1 (17.3) [316] | 27.0 | 56.06% | Pplat |
| Property Name | Engine Value |
|---|---|
| Patient-Height(in) | 69.0 |
| Patient-IdealBodyWeight(kg) | 70.7 |
| InspiratoryRespiratoryResistance(cmH2O_s/L) | 14.8 |
| ExpiratoryRespiratoryResistance(cmH2O_s/L) | 14.8 |
| RespiratoryCompliance(mL/cmH2O) | 21.1 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.616 |
| ClinicalShuntFraction | 0.762 |
| MechanicalVentilator-TidalVolume(L) | 0.451 |
| BloodPH | 7.33 |
| Aorta-Oxygen-PartialPressure(mmHg) | 24.6 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 46.1 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.3 |
| OxygenSaturation | 0.482 |
| HorowitzIndex(mmHg) | 61.7 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.0391 |
| MechanicalVentilator-RespirationRate(1/min) | 24.4 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 10.3 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 37.6 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 27.0 |
| HeartRate(1/min) | 190 |
| SystolicArterialPressure(mmHg) | 86.1 |
| DiastolicArterialPressure(mmHg) | 76.3 |
| MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 11.0 |
| MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 14.8 |
| MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 14.8 |
| MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 20.5 |
| MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 13.8 |
| MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 20.7 |
| MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 281 |
| MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.451 |
| MechanicalVentilator-InspiratoryExpiratoryRatio | 0.295 |
| MechanicalVentilator-InspiratoryTidalVolume(L) | 0.451 |
| MechanicalVentilator-PeakExpiratoryFlow(L/s) | 1.05 |
| MechanicalVentilator-LeakFraction | 0.00 |
| MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.0424 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 5.04 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.377 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 33.2 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 5.04 |
| EndTidalCarbonDioxidePressure(mmHg) | 21.9 |
| PhysiologicDeadSpace(mL) | 274 |
| AlveolarArterialGradient(mmHg) | 124 |
| AlveolarDeadSpace(mL) | 132 |
| AnatomicDeadSpace(mL) | 141 |
| ChestWallCompliance(L/cmH2O) | 0.0689 |
| FractionOfInspiredOxygen | 0.399 |
| LungCompliance(L/cmH2O) | 0.0322 |
| VentilationPerfusionRatio | 1.39 |
| HeartStrokeVolume(mL) | 16.3 |
| HeartEjectionFraction | 0.239 |
| BloodVolume(L) | 5.53 |
| MeanArterialPressure(mmHg) | 80.9 |
| PulsePressure(mmHg) | 9.82 |
| CardiacOutput(L/min) | 3.11 |
| CarbonDioxideSaturation | 0.226 |
| RespiratoryExchangeRatio | 0.833 |
| SystemicVascularResistance(mmHg_s/mL) | 1.35 |
| OxygenConsumptionRate(mL/min) | 224 |
| CarbonDioxideProductionRate(mL/min) | 187 |
| Patient-AlveoliSurfaceArea(m^2) | 12.8 |
| Patient-ExpiratoryReserveVolume(L) | 0.820 |
| Patient-FunctionalResidualCapacity(L) | 1.21 |
| Patient-InspiratoryCapacity(L) | 2.93 |
| Patient-InspiratoryReserveVolume(L) | 2.41 |
| Patient-ResidualVolume(L) | 0.393 |
| Patient-TidalVolumeBaseline(L) | 0.516 |
| 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
| Property Name | Validation | Engine Value | Percent Error | Percent Change | Notes |
|---|---|---|---|---|---|
| MechanicalVentilator-TidalVolume(mL) | EqualTo 488 | 484 | -0.76% | VT (measured) | |
| RespiratoryCompliance(mL/cmH2O) | GreaterThan Segment2 (21.1) [316] | 39.1 | 85.18% | C | |
| SystolicArterialPressure(mmHg) | GreaterThan Segment2 (86.1) [316] | 109 | 26.72% | BP | |
| DiastolicArterialPressure(mmHg) | GreaterThan Segment2 (76.3) [316] | 81.9 | 7.31% | BP | |
| Aorta-Oxygen-PartialPressure(mmHg) | GreaterThan Segment2 (24.6) [193] | 57.2 | 132.42% | PaO2 | |
| OxygenSaturation | GreaterThan Segment2 (0.482) [316] [320] | 0.902 | 87.26% | SpO2 | |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | LessThan Segment2 (37.6) [316] | 27.2 | -27.69% | PIP | |
| MechanicalVentilator-PlateauPressure(cmH2O) | LessThan Segment2 (27.0) [316] | 17.7 | -34.72% | Pplat |
| 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) | 39.1 |
| ClinicalPhysiologicDeadSpaceTidalVolumeRatio | 0.383 |
| ClinicalShuntFraction | 0.343 |
| MechanicalVentilator-TidalVolume(L) | 0.484 |
| BloodPH | 7.33 |
| Aorta-Oxygen-PartialPressure(mmHg) | 57.2 |
| Aorta-CarbonDioxide-PartialPressure(mmHg) | 45.5 |
| Aorta-Bicarbonate-Molarity(mEq/L) | 26.3 |
| OxygenSaturation | 0.902 |
| HorowitzIndex(mmHg) | 143 |
| IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.316 |
| MechanicalVentilator-RespirationRate(1/min) | 24.0 |
| MechanicalVentilator-MeanAirwayPressure(cmH2O) | 9.00 |
| MechanicalVentilator-PeakInspiratoryPressure(cmH2O) | 27.2 |
| MechanicalVentilator-PlateauPressure(cmH2O) | 17.7 |
| HeartRate(1/min) | 117 |
| SystolicArterialPressure(mmHg) | 109 |
| DiastolicArterialPressure(mmHg) | 81.9 |
| MechanicalVentilator-TotalPulmonaryVentilation(L/min) | 11.6 |
| MechanicalVentilator-InspiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-ExpiratoryResistance(cmH2O_s/L) | 12.4 |
| MechanicalVentilator-StaticRespiratoryCompliance(mL/cmH2O) | 39.0 |
| MechanicalVentilator-DynamicRespiratoryCompliance(mL/cmH2O) | 21.8 |
| MechanicalVentilator-EndTidalCarbonDioxidePressure(mmHg) | 35.1 |
| MechanicalVentilator-EndTidalOxygenPressure(mmHg) | 266 |
| MechanicalVentilator-ExpiratoryTidalVolume(L) | 0.484 |
| MechanicalVentilator-InspiratoryExpiratoryRatio | 0.316 |
| MechanicalVentilator-InspiratoryTidalVolume(L) | 0.484 |
| MechanicalVentilator-PeakExpiratoryFlow(L/s) | 0.782 |
| MechanicalVentilator-LeakFraction | 0.00 |
| MechanicalVentilator-IntrinsicPositiveEndExpiratoryPressure(cmH2O) | 0.243 |
| MechanicalVentilator-ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| MechanicalVentilator-TotalPositiveEndExpiratoryPressure(cmH2O) | 5.24 |
| PhysiologicDeadSpaceTidalVolumeRatio | 0.553 |
| PhysiologicShuntFraction | 0.364 |
| TotalRespiratoryModelInspiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelExpiratoryResistance(cmH2O_s/L) | 12.4 |
| TotalRespiratoryModelCompliance(mL/cmH2O) | 48.8 |
| ExtrinsicPositiveEndExpiratoryPressure(cmH2O) | 5.00 |
| TotalPositiveEndExpiratoryPressure(cmH2O) | 5.32 |
| EndTidalCarbonDioxidePressure(mmHg) | 38.3 |
| PhysiologicDeadSpace(mL) | 274 |
| AlveolarArterialGradient(mmHg) | 202 |
| AlveolarDeadSpace(mL) | 132 |
| AnatomicDeadSpace(mL) | 141 |
| ChestWallCompliance(L/cmH2O) | 0.111 |
| FractionOfInspiredOxygen | 0.399 |
| LungCompliance(L/cmH2O) | 0.0644 |
| VentilationPerfusionRatio | 0.829 |
| HeartStrokeVolume(mL) | 52.3 |
| HeartEjectionFraction | 0.455 |
| BloodVolume(L) | 5.51 |
| MeanArterialPressure(mmHg) | 95.7 |
| PulsePressure(mmHg) | 27.3 |
| CardiacOutput(L/min) | 6.12 |
| CarbonDioxideSaturation | 0.175 |
| RespiratoryExchangeRatio | 0.798 |
| SystemicVascularResistance(mmHg_s/mL) | 0.886 |
| OxygenConsumptionRate(mL/min) | 249 |
| CarbonDioxideProductionRate(mL/min) | 198 |
| Patient-AlveoliSurfaceArea(m^2) | 12.8 |
| Patient-ExpiratoryReserveVolume(L) | 0.820 |
| Patient-FunctionalResidualCapacity(L) | 1.21 |
| Patient-InspiratoryCapacity(L) | 2.93 |
| Patient-InspiratoryReserveVolume(L) | 2.41 |
| Patient-ResidualVolume(L) | 0.393 |
| Patient-TidalVolumeBaseline(L) | 0.516 |
| Patient-TotalLungCapacity(L) | 4.14 |
| Patient-VitalCapacity(L) | 3.75 |
Scenario Output Plots
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
 |
|