Hot case — sudden collapse on the turn in a proned patient

A CICM Second-Part hot case — the College's hallmark real-patient bedside encounter. The candidate works through the dangerous event that immediately follows a turn in a proned severe-ARDS patient: the acute differential (tube obstruction or migration on the turn, tension pneumothorax, right-ventricular failure, plugging, circuit loss), the bedside acts that localise it, the decision to return to prone or stay supine, and the defence of the lung-protective strategy throughout.

Prompt

You are handed a 45-year-old woman in bed 4. She has severe influenza ARDS (PaO2/FiO2 70) and is being managed lung-protectively with prolonged prone cycles. She was just turned back to supine for her planned rest period and within a minute her saturation has fallen to 78%, the peak airway pressure has spiked, and her blood pressure has dropped to 84/50 mmHg. The nurse has your attention. You have eight minutes to examine her at the bedside and present a focused assessment and plan before the examiner joins you.

Presentation

Candidate brief. Mrs K, 45, day 5 of confirmed influenza A severe ARDS (admission PaO2/FiO2 70), ventilated lung-protectively on FiO2 0.8, PEEP 14, tidal volume 360 mL, and managed with prolonged prone cycles of at least 16 hours as her mortality-reducing therapy. She has tolerated proning well until now. She was just turned back to supine for her planned rest period and within a minute the saturation fell from 92% to 78%, the peak airway pressure spiked from 32 to 48 cmH2O, and the blood pressure fell from 110/65 to 84/50 mmHg, heart rate 122. The nurse has called you to the bedside.

^[1]

You have eight minutes to review the chart, examine her, and prepare a structured assessment before the examiner arrives.^[6]

References7Show

[1]Guérin C, Reignier J, Richard JC, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2013.PMID 23688302
[2]Brower RG, Matthay MA, Morris A, et al. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2000.PMID 10793162
[3]Amato MBP, et al. Driving Pressure and Survival in the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2015.PMID 25693014
[4]Gattinoni L, et al. Regional Physiology of ARDS. Critical Care, 2017.PMID 29297365
[5]Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2018.PMID 29791822
[6]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
[7]Marino PL The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.

Hot case — sudden collapse on the turn in a proned patient

Presentation

You have eight minutes to review the chart, examine her, and prepare a structured assessment before the examiner arrives.^[6]

References7Show

[1]Guérin C, Reignier J, Richard JC, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2013.PMID 23688302
[2]Brower RG, Matthay MA, Morris A, et al. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2000.PMID 10793162
[3]Amato MBP, et al. Driving Pressure and Survival in the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2015.PMID 25693014
[4]Gattinoni L, et al. Regional Physiology of ARDS. Critical Care, 2017.PMID 29297365
[5]Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2018.PMID 29791822
[6]Bersten AD, Soni N (eds) Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
[7]Marino PL The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.