Case by George Nassar MD, Inova PEM Fellow

A 14-year-old male, with no significant past medical history is brought by EMS to the ER from an outside urgent care because of hypoxia. He has had low-grade fevers (Tmax 101 F) and a productive cough for 2 days. At the urgent care, he was noted to be hypoxic to 84% but otherwise had no increased work of breathing or signs of respiratory distress. He was given a DuoNeb without improvement, placed on a NRB which brought O2 sats up to 90%, and then brought to our ER. No recent travel.  

ROS: Negative for headache, chest pain, shortness of breath or chest tightness, dyspnea, fatigue, abdominal pain, vomiting, diarrhea, or rash.

Exam:Temp: 99.3 °F (37.4 °C), Heart Rate: 110, BP: 111/66, Resp Rate: 24, SpO2: 87 % on NRB@15L Weight: 41 kg

Appearance: Normal appearance. No acute distress
HENT: NC/AT, Normal TM’s. Nares clear without drainage. Oropharynx clear. MMM
Eyes: Pupils: Pupils are equal, round, and reactive to light. EOMI. Clear anicteric
Cardiovascular: Normal rate and regular rhythm. Normal pulses. Normal S1/S2 no m/r/g
Pulmonary: Normal effort. No respiratory distress. No stridor. No wheezing, rhonchi, or rales. Decreased aeration on right upper and lower lung fields compared to left side
Chest: No chest wall tenderness
Abdominal: Flat, non-distended, non-tender abdomen
Skin: Brisk cap refill. B/l fingers appear cyanotic without obvious clubbing. No other peripheral or central cyanosis. There are no stigmata of vascular lesions on the chest wall or abdomen.
Neurological: AAOx3. No FND

i-Stat VBG: 7.36/34.4/22/19.4 on NRB

CBC: 6.36 <18.2/53.7 <220. Nothing abnormal on differential. MCV 89.

EKG: NSR, vent rate 108. Normal intervals. No ST changes. No RVH. Possible LVH

MetHb level normal. CarboxyHb level normal. Oxygenated Hb = 73% (Normal 85-98%)

He was switched over to HFNC 20 LPM 50% eventually requiring an increase in FiO2 to 70-80% to keep saturations >90%.

Bedside POCUS with good lung-sliding. Normal cardiac contractility. No pericardial effusions.

CTA results showed…