CHEST Guidelines-Prolonged-Respiratory-Failure-From-COVID-19-With-N

Prolonged-Respiratory-Failure-From-COVID-19-With-N

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The article discusses a clinical case involving a 68-year-old man who experienced prolonged respiratory failure due to COVID-19-induced acute respiratory distress syndrome (ARDS) and developed new-onset shock. Initially requiring a tracheostomy and treatment for ventilator-associated pneumonia, his condition worsened with shock symptoms, including hypotension and altered laboratory values, such as high lactate and decreased hemoglobin levels.<br /><br />On admission to the ICU, bedside ultrasound revealed an extrathoracic fluid collection identified as a hematoma, suggesting a bleed as the shock's cause. Further investigation, including CT imaging and angiography, confirmed active arterial extravasation from the 4th and 5th intercostal arteries, diagnosing a spontaneous intercostal arterial hemorrhage. This bleeding was attributed to anticoagulation therapy with enoxaparin, a low-molecular-weight heparin administered for a previously treated deep vein thrombosis (DVT).<br /><br />The patient was stabilized with red blood cell transfusion and underwent successful embolization by interventional radiology, resolving the shock.<br /><br />The article highlights the importance of point-of-care ultrasound in diagnosing shock causes within ICU settings. It also outlines the anatomical vascular consideration for the intercostal arteries and the imaging challenges associated with chest wall hematomas, which can vary sonographically. Enoxaparin's role as an anticoagulant and its associated bleed risk, particularly the lack of a straightforward reversal agent, are also discussed.<br /><br />Overall, it emphasizes the diagnostic value of bedside ultrasound and multidisciplinary interventions in managing complex ICU presentations and the need for caution in anticoagulant use, especially in patients with predisposing factors for bleeding.

Keywords

COVID-19

ARDS

shock

tracheostomy

hematoma

enoxaparin

intercostal arteries

ultrasound

embolization

anticoagulation