Medic 4 / I-80 · 18 min · ground

Night MVC — pulmonary contusion

ARDSNet ARMA / ALVEOLI · ATS 2024 · 88–95% (ARDSNet ARMA; PaO2 55–80 mmHg) · ARDSNet / SSC: 6 mL/kg PBW; drop 1 mL/kg toward 4 if Pplat >30 · Pplat ≤30 · ΔP ≤14 (trainer) · PaCO2 ~35–45

Rural interstate. 34-year-old restrained driver, prolonged extrication. Right chest wall tender, sat 86% on NRB, now tubed 7.5 at 22 cm. Contusion is focal ARDS — same ARDSNet rules.

Handoff

Bagging at 16, hard to squeeze. BP 98/64 after 1U PRBC. They left him APVcmv 620 mL (~8.5 mL/kg) PEEP 5 FiO2 100. That is not a table pair. Height 178 cm male → PBW ~73 kg. Convert to PCV+ or (S)CMV+. ARDSNet: 6 mL/kg, Pplat ≤30, SpO2 88–95, PEEP with FiO2. Don't blow the right lung.

1
ARDSNet VT 6 mL/kg PBW — drop toward 4 if Pplat >30
178 cm male ≈ 73 kg. 6 mL/kg ≈ 440 mL. Sending 620 mL is 8.5 mL/kg — cut it.
2
PEEP/FiO2 on the ARDSNet table — PEEP 5 / FiO2 100 is not a pair
Lower table at FiO2 0.60 = PEEP 10. Wean O2 into 88–95, then PEEP follows. Occult pneumo: falling VTE at the same Pinsp, not more PEEP.
3
SpO2 88–95% (PaO2 55–80) without dumping MAP
Same ARMA oxygenation goal as the viral ARDS case. MAP ≥65 — he is dry.

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