Case 3

A 56-year-old patient is brought in by a blue light ambulance for acute shortness of breath. The paramedics have treated him with nebulised Salbutamol and given him high-flow oxygen.

On arrival in resus he is cyanosed, has an irregular pulse rate of 168/min,  Blood Pressure of 170/56 mm Hg, respiratory rate of 34/min, SpO₂ of 88% on a reservoir mask and temperature of 37.8^oC. He has widespread crackles and wheeze on auscultation.

You note a recent sternotomy scar and the patient’s wife tells you he had a CABG and valve replacement 4 weeks ago. She says he has had a temperature for a few days and has not really perked up after his operation.

List appropriate differential diagnoses for this patient.

This patient is very unwell and in severe respiratory distress. You must follow a systematic ABC approach. Ensure the patient is comfortable, institute high-flow oxygen, obtain intra-venous access, obtain blood samples for counts, cultures, INR and biochemistry and request ECG and chest X-ray.

The patient is able to tell you his name and denies any chest pain. You sit him upright and ensure that he has a tight fitting mask with reservoir bag on 15 l/min of oxygen.

ECG results (click the image)	Arterial Blood Gas Results	Urgent CXR (click the image)
	pH:  7.29 pO2:  7.5 kPa pCO2:  5.2 kPa HCO3:  22 mmol/l BE:  -6 Lactate: 2.8 mmol/l

Choose one step as the most appropriate as your next step in management of this patient.

Which of the following should be considered at this time?