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+EMCrit [sorry if this ends up being a re-post - new to google+]...
Hi Scott, 

Had an intense night shift the other night. One of my patients was a middle aged guy who came in from the train station (homeless, covered with urine and feces) agitated when aroused but otherwise slumped over and hypoxic (sat 75% on RA, 88-89% on NRB). Narcan from attending didn't work. I heard coarse rhonchi and figured him for likely aspiration PNA. I made the decision to intubate. Breath sounds were louder on the right side, but the chest XR showed proper tube positioning. It also showed dense infiltrate on the left with essentially whited-out lung (right side had lower lobe infiltrate). Initial settings: Vol A/C, Vt 450, RR 18, 100%/5. P/F ratio on initial gas was dismal (FiO2 100% and PaO2 of 80 at best). ARDS! I began titrating his vent with respiratory at the bedside, closely following the monitor and sending off ABGs every 10 min or so. His plateau was very high (35-38) and finally hit 28 once I reached 300 Vt. I had his PEEP up to 18 (highest I've ever done!) and FiO2 80, which kept him at a monitor sat of 89-90%. RR was titrated up to 26 (PaCO2 90s - 100). He went up to the ICU later on. The fellow guided the ICU residents over the phone to increase Vt to 400, drop PEEP to 12, and keep FiO2 100%. I'm not sure why and didn't get the chance to ask him. Regardless, this was an arduous case and a wonderful application of the ARDSnet protocol and your clinical teachings. Thanks for that!! Would you have done something different?
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