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Tachypnea in a Patient With Severe Anemia


Case Study

A rapid response event was activated by the bedside nurse for a patient who developed acute respiratory distress. Upon the arrival of the rapid response team, it was found that the patient was a 55-year-old male with a history of alcohol abuse, chronic obstructive pulmonary disease (COPD), congestive heart failure (most recent left ventricular ejection fraction 20%) who initially presented for evaluation of chest pain. Emergent cardiac catheterization was performed through the femoral artery, and two coronary stents were placed. Overnight, the patient developed increasing difficulty breathing associated with tachycardia.

Vital Signs

  • Temperature: 37.4 °F

  • Blood Pressure: 90/60 mmHg

  • Heart Rate: 120 beats per min – with sinus tachycardia on tele-monitor

  • Respiratory Rate: 35 breaths per min

  • Pulse Oximetry: 85% on room air, improved to 97% on 2 L oxygen

Focused History and Physical Examination

A middle-aged male who was visibly in distress was seen. Lungs and heart were clear on auscultation. However, the patient appeared dyspneic and was using accessory muscles of respiration. Abdominal examination was unremarkable, but inguinal examination showed bruising around the puncture site with associated swelling. The remaining examination was unremarkable.

Interventions

Based on the history and physical examination, the patient appeared to be in acute hypoxic respiratory failure. He was placed on 2 L of supplemental oxygen through a nasal cannula, and 1 L of IV fluid bolus was initiated. A cardiac monitor was attached. Stat chest X-ray, arterial blood gas, EKG, brain natriuretic peptide (BNP), troponin, and basic labs were ordered. The chest X-ray was negative for any acute infiltrates. Arterial blood gas showed a pH of 7.59, pCO2 of 22, and pO2 of 52, which was significant for alkalosis and hypoxemia. Basic labs showed hemoglobin 4.1 mg/dL. His other labs were unremarkable. Computed tomography (CT) angiography of chest, abdomen, and pelvis was ordered stat to assess for an occult bleed. The patient was given an urgent blood transfusion and admitted to the intensive care unit for closer monitoring. Interventional radiology was consulted to evaluate for possible embolization.

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