Upon assessment of your patient, their breathing rate is 24, they have a toxic appearance, and an SpO2 of 90%. You plan to call the MD to report your findings.
What do you anticipate that she will order?

Choice A rationale

Metabolic acidosis is characterized by a primary decrease in bicarbonate (HCO3), typically below the normal range of 22-26 mmol/L, leading to a reduction in pH. Partial compensation would involve a compensatory decrease in PaCO2, normally 35-45 mm Hg. The given arterial blood gas values do not align with these characteristics, as the pH is elevated and HCO3 is within normal limits.

Choice B rationale

Respiratory alkalosis is defined by a primary decrease in PaCO2, below the normal range of 35-45 mm Hg, resulting in an elevation of pH above 7.45. Uncompensated respiratory alkalosis means the bicarbonate level (normal range 22-26 mmol/L) remains within normal limits as the kidneys have not yet had time to excrete bicarbonate to compensate. The provided pH of 7.6 and PaCO2 of 31 mm Hg, with HCO3 of 25 mmol/L, perfectly match these criteria.

Choice C rationale

Respiratory acidosis is characterized by a primary increase in PaCO2, above the normal range of 35-45 mm Hg, leading to a decrease in pH below 7.35. Partial compensation would involve a compensatory increase in bicarbonate. The given arterial blood gas values, particularly the elevated pH and decreased PaCO2, directly contradict the definition of respiratory acidosis.

Choice D rationale

Metabolic alkalosis is defined by a primary increase in bicarbonate (HCO3), typically above the normal range of 22-26 mmol/L, leading to an elevation of pH above 7.45. Partial compensation would involve a compensatory increase in PaCO2. The given arterial blood gas values do not show an elevated bicarbonate level that would indicate a primary metabolic issue.

Choice A rationale

The patient's initial unconsciousness, followed by a lucid interval and then declining consciousness (appearing to fall asleep, unable to verbally reply), is a classic presentation of an epidural hematoma. This condition requires immediate medical attention as expanding hematomas can lead to brain herniation. Notifying the MD and preparing for a burr-hole procedure to relieve intracranial pressure is the highest priority to prevent irreversible brain damage.

Choice B rationale

While pain management is important, it is not the priority in a patient with a rapidly deteriorating neurological status. Administering pain medication without addressing the underlying intracranial pathology could mask critical neurological signs and delay life-saving interventions. The immediate concern is the potential for brain compression, not comfort.

Choice C rationale

Placing the patient on a nasal cannula at 2 Lpm for a patient with deteriorating consciousness is insufficient and potentially inappropriate. If the patient's respiratory drive is compromised due to increased intracranial pressure, more aggressive airway management, potentially intubation, might be required. Oxygenation should be assessed and managed, but it is not the initial priority without evaluating the airway and breathing comprehensively in a declining patient.

Choice D rationale

Obtaining a stat EKG is not the priority action in a patient presenting with acute neurological deterioration following head trauma. While cardiac function is important, the immediate threat to life in this scenario is neurological compromise due to potential intracranial bleeding and rising intracranial pressure. An EKG would be a secondary assessment after stabilizing the primary neurological issue.