What are the appropriate treatment and workup for a 49-year-old female presenting to the Emergency Room (ER) with back pain, severe hypoxemia (less than 35 mmHg Oxygen (O2)), respiratory alkalosis (pH 7.49), hypercapnia (Carbon Dioxide (CO2) 48), tachycardia (heart rate in the 120s), hypotension (blood pressure 96/66), elevated Creatine Kinase (CK) (6386), and elevated liver enzymes (Aspartate Aminotransferase (AST) 448, Alanine Aminotransferase (ALT) 80), currently on high flow Oxygen (O2) therapy?

From the Guidelines

The patient should be treated for septic shock with aggressive fluid resuscitation and broad-spectrum antibiotics, and considered for mechanical ventilation due to severe hypoxemia and hypercapnia.

Initial Assessment and Management

• The patient's presentation with severe hypoxemia (O2 less than 35 mmHg), respiratory alkalosis (pH 7.49), hypercapnia (CO2 48), tachycardia (heart rate in the 120s), hypotension (blood pressure 96/66), elevated Creatine Kinase (CK) (6386), and elevated liver enzymes (AST 448, ALT 80) suggests a diagnosis of sepsis with organ dysfunction, which meets the criteria for septic shock as defined by the presence of sepsis-induced arterial hypotension despite adequate fluid resuscitation and signs of tissue hypoperfusion 1.
• The patient is currently on high flow Oxygen (O2) therapy, which is appropriate for severe hypoxemia, but may require mechanical ventilation if there is no improvement or if the patient's condition worsens.

Ventilatory Management

• The BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults recommends considering non-invasive ventilation (NIV) in patients with type 2 respiratory failure and a PaCO2 between 6.0 and 6.5 kPa, but starting NIV when pH < 7.35, PaCO2 ≥ 6.5 kPa, and RR > 23 breaths/min persists or develops after an hour of optimal medical therapy 1.
• In patients with acute hypercapnic respiratory failure, a low tidal volume strategy improves survival, and permissive hypercapnia may be tolerated with a pH above 7.2 1.

Fluid Resuscitation and Vasopressor Support

• Fluid resuscitation should be aggressive, with the goal of achieving adequate tissue perfusion and blood pressure support, but should be stopped or interrupted if there is no improvement in tissue perfusion or if fluid overload occurs 1.
• Vasopressor support may be necessary to maintain blood pressure and perfusion of vital organs.

Antibiotic Therapy

• Broad-spectrum antibiotics should be started empirically, with the choice of antibiotic guided by the suspected source of infection and local antibiotic resistance patterns.

Monitoring and Support

• The patient should be closely monitored in the intensive care unit (ICU), with frequent assessment of vital signs, oxygenation, ventilation, and organ function.
• Supportive care, including pain management, sedation, and nutritional support, should be provided as needed.

From the Research

Presentation and Initial Assessment

The patient presents with severe back pain, hypoxemia, respiratory alkalosis, hypercapnia, tachycardia, hypotension, elevated Creatine Kinase (CK), and elevated liver enzymes. The initial assessment should focus on stabilizing the patient and addressing the immediate life-threatening conditions.

Laboratory Findings

• Elevated CK (6386) and liver enzymes (AST 448, ALT 80) suggest muscle and liver damage, which could be due to various causes, including physical activity 2, obesity 3, or other underlying conditions.
• The AST to ALT ratio may be useful in predicting acute kidney injury after cardiac surgery 4, but its relevance to this patient's presentation is unclear.

Differential Diagnosis

• The patient's presentation of severe back pain and elevated CK activity could suggest a variety of life-threatening conditions, including muscular or skeletal injuries, or even a sensory demyelinating neuropathy 5.
• The elevated liver enzymes could be related to obesity 3 or other liver diseases, but the patient's current presentation and lack of family history of liver disease make it difficult to determine the exact cause 6.

Treatment and Workup

• The patient is currently on high flow Oxygen (O2) therapy, which is appropriate for addressing the hypoxemia.
• Further workup should include a thorough physical examination, imaging studies (e.g., chest and abdominal X-rays, CT scans), and laboratory tests (e.g., complete blood count, electrolyte panel, liver function tests) to determine the underlying cause of the patient's symptoms.
• The patient's muscle and liver damage should be monitored and addressed accordingly, with potential treatments including pain management, physical therapy, and liver-protective medications.
• Consideration should be given to the potential for acute kidney injury, particularly if the patient undergoes cardiac surgery 4.