A previously healthy 35-year-old woman is brought into the emergency department after being found unresponsive by her husband. Her husband finds an empty bottle of diazepam tablets in her pocket. She is stuporous. At the hospital, her blood pressure is 90/40 mm Hg, the pulse is 58/min, and the respirations are 6/min. The examination of the pupils shows normal size and reactivity to light. Deep tendon reflexes are 1+ bilaterally. Babinski sign is absent. All 4 extremities are hypotonic. The patient is intubated and taken to the critical care unit for mechanical ventilation and treatment. Regarding the prevention of pneumonia in this patient, which of the following strategies is most likely to achieve this goal?
ANasogastric tube insertion
BDaily evaluation for ventilator weaning
CSubglottic drainage of secretions
DOropharynx and gut antibacterial decontamination
EProne positioning during mechanical ventilation
A 63-year-old man with alpha-1-antitrypsin deficiency is brought to the emergency department 1 hour after his daughter found him unresponsive. Despite appropriate care, the patient dies. At autopsy, examination of the lungs shows enlargement of the airspaces in the respiratory bronchioles and alveoli. Enzymatic activity of which of the following cells is the most likely cause of these findings?
AAlveolar macrophages
BCiliated bronchiolar epithelial cells
CElastic fibers in alveolar septa
DType I pneumocytes
EAlveolar septal cells
A 63-year-old man is brought to the emergency department, 30 minutes after being involved in a high-speed motor vehicle collision. He is obtunded on arrival. He is intubated and mechanical ventilation is begun. The ventilator is set at a FiO2 of 60%, tidal volume of 440 mL, and positive end-expiratory pressure of 4 cm H2O. On the third day of intubation, his temperature is 37.3°C (99.1°F), pulse is 91/min, and blood pressure is 103/60 mm Hg. There are decreased breath sounds over the left lung base. Cardiac examination shows no abnormalities. The abdomen is soft and not distended. Arterial blood gas analysis shows: pH 7.49 pCO2 29 mm Hg pO2 73 mm Hg HCO3- 20 mEq/L O2 saturation 89% Monitoring shows a sudden increase in the plateau airway pressure. An x-ray of the chest shows deepening of the costophrenic angle on the left side. Which of the following is the most appropriate next step in management?
ACT scan of the chest
BAdminister levofloxacin
CClose observation
DIncrease the PEEP
EInsertion of a chest tube
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