Emphysema

William S. Marlborough, III is a 63 year old commodities trader. This multi-millionaire made his fortune in tobacco futures. Born in North Carolina, he has gone through four wives, numerous holding companies, and three packs of unfiltered cigarettes every day since his teens. In the last year, he has also gone through 2 liter/min. of home oxygen for his emphysema. He told his doctor he had stopped smoking.

Today he became SOB (short of breath) enroute to a business meeting. His chauffeur brought him to the ER at noon. His chief complaint is "I have a cold and my doctor gave me the wrong antibiotic." For three days he's had increasing cough, phlegm, and SOB despite upping his home oxygen to 3 liter/min. He feels weak and feverish but "must" be at his meeting by 1:00.

On arrival, he is acutely SOB. His vital signs are T: 102.0 F, P: 120/min. and irregular, R: 20/min. and labored, BP: 168/88. His skin is hot and damp and his lips and nails are bluish (cyanotic). Listening to his chest, you hear scattered wheezes and very decreased breath sounds in both lungs. His pulse ox is only 85% despite his 3 liter/min. oxygen.

Regardless of his pressing meeting, a CBC, blood gases, EKG, and chest x-ray are done. The CBC shows a hemoglobin of 16gms and a hematocrit of 48%. EKG shows a fast heart rate with extra beats. Chest x-ray shows emphysema and pneumonia. His ABG's are:

Q: Does this patient need blood?

Q: Does he need oxygen?

Q: How MUCH oxygen does he need?

Q: Is his pH normal?

Q: Why not?

Q: Isn't this a respiratory problem? Why worry about HCO₃ which is metabolic?

Q: Well how could it be worse? Does he have a metabolic problem as well?

Q: Are you sure?

Q: What is his ABG diagnosis?

Q: What does he need for treatment?

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