mortality meet presentation by dr. saumya agarwal
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TRANSCRIPT
MORTALITY MEET
PRESENTER- Dr. Saumya Agarwal
Junior resident Dept of Orthopaedics
J.N.Medical College and Dr. Prabhakar Kore
Hospital and MRC, Belgaum
PARTICULARS
Name- ABC
Age- 45 yrs
Sex- Female
IP No. – 123456
Occupation- housewife
Address- Vishrantwadi, Pune
DOA - 01/05/15
DOS – 14/05/15
DOE - 29/05/15
CHIEF COMPLAINTS
Patient came to the casualty
unconscious following road traffic
accident- 4 wheeler was hit by
another 4 wheeler
HISTORY OF PRESENTING ILLNESS
Patient met with a road traffic accident
and sustained injuries over right lower
thigh and right eye laterally as told by the
attender
Patient is unconscious, cut lacerated
wound present over right lower thigh and
right eye laterally
History of vomiting present 2 episodes
Bleeding from nose and ear present
No history of seizures
PAST HISTORY
No history of Diabetes Mellitus 2 and
Hypertension
No history of Ischaemic Heart
Disease/Tuberculosis/Asthma
PERSONAL HISTORY
No addictive habits
FAMILY HISTORY
Not Significant
GENERAL PHYSICAL EXAMINATION
Patient is well built and nourished
Unconscious
Pallor present
No Icterus
Clubbing
Lymphadenopathy
Edema
Cyanosis
Multiple hypopigmented dry scaly
lesions present over the trunk, back
and groin region suggestive of eczema
Multiple erythematous plaques present
over left side of neck
VITALS
Temperature- Afebrile
Pulse – 92/min
Blood pressure- 90/60 mmHg
Respiratory rate – 34/min
SPO2 – 95%
SYSTEMIC EXAMINATION
CVS – tachycardia, S1 and S2 heard,
No murmurs
RS – Tachypnea
P/A - Soft, no organomegaly, bowel
sounds heard
CNS – unconscious
Glasgow Coma Scale E1V1M4
6/15
Revised Trauma Score
GCS2 SBP4 RR3 9/12
Pupils sluggish reacting to light
INSPECTION
Patient was lying in supine position unconscious
Bleeding present from nose and right ear
Active bleeding present over cut lacerated wound around 3x2 cm at lateral side of right eye
RIGHT LOWER LIMB :
Attitude of the right lower limb was
externally rotated and abducted
Active bleeding present over cut lacerated
wound around 4x2 cm at distal right thigh
Deformity seen at right thigh
Diffuse swelling present
No engorged veins or sinuses
No visible pulsations
PALPATION
Inspectory findings are confirmed
Local rise of temperature present
Crepitus present
Abnormal mobility present
Diffuse swelling present
ROM of right hip and knee – passive movtsexaggerated at hip
Active bleeding present over cut lacerated wound around 4x2 cm at distal right thigh
Pelvic compression test and chest compression test negative
limb length discrepancy present
B/L Peripheral pulses feeble
Toe movements cannot be elicited
MANAGEMENT
Patient was intubated in resuscitation room
Crysatalloids @ 100 ml/hr were given and haemaccel 3.5% was also given
Both the cut lacerated wounds were sutured
Thomas splint given
Investigations sent
Patient was shifted to ICU and ryle’s tube inserted
CT-Brain was performed
CT-Brain showed tiny hemorrhagic contusion in the left frontal region measuring 6x3mm
Few streaks of subarachnoid hemorrhage in right frontal and temporal regions
Evidence of fracture of lateral wall of orbit on right side
CT BRAIN
X-Rays were performed
bed side
CHEST X-RAY
X-RAY PELVIS WITH B/L HIP AP VIEW
X-RAY RIGHT FEMUR AP VIEW
X-RAY CERVICAL SPINE
CT-B/L Hip showed comminuted
intertrochanteric fracture of right femur with
breech in transcervical region
right obturator internus appears to be bulky
suggestive of hematoma
left hip was normal
CT-Thorax showed bilateral minimal
pleural effusion
CT HIP AND THORAX
INVESTIGATIONS
Hb – 12.2 gm% 1/5/15
WBC - 15000/cmm
Differential count – N86, L06, E00, M06, B02
ESR – 30 mm
PCV – 25 %
Platelet Count - 2.68 lakhs/cmm
RBC - 4.51 millions/cmm
Blood Urea – 26 mg/dl
S. Creatinine – 1.15mg/dl
S. Sodium - 134meq/l
S.Potassium - 3.94meq/l
S.Uric acid -5.5mg/dl
Blood group – B +
Total bilirubin – 0.52
Direct bilirubin – 0.12
SGOT – 80
SGPT – 59
Total proteins – 6.2
S. albumin – 3.3
S. calcium – 7.2
S. PCT – 0.514 mg/ml
Osmolality – 270 mOsm/kg
PT – 14.1 sec
APTT – 28 sec
INR – 1.26
HIV 1 and 2 non reactive
HBsAg non reactive
HCV non reactive
ECG was within normal limits
ARTERIAL BLOOD GAS ANALYSIS
pH 7.48
pCO2 29.8
pO2 56.5
HCO3 21.8
Continously she was in metabolic alkalosis with respiratory alkalosis
Hct – 28.7 %
S lactate – 3.5 mmol/lit
RBS – 126 mg/dl
TREATMENT
Intra venous fluids at 100 ml/hr 1pint NS/RL
Inj Zoact 1gm iv 1-0-1
Inj Amikacin 500mg iv 1-0-1
Inj Mezol 100 ml iv 1-1-1
Inj Pantocid 40 mg iv 1-0-1
Inj Dynapar AQ in 100 ml NS 1-0-1
Inj Emset 4mg iv 1-0-1
Inj methylprednisolone 0-1-0
Inj eptoin 100 mg 1-1-1
Pt was put on O2 at 5 lit/min
1 pint whole blood was transfused on 2nd day
TPR-BP charting was performed hourly
Input output charting was done on daily basis
REFERENCES WERE GIVEN TO :
Neurosurgery
Ophthalmology
OMFS
Respiratory Medicine
Physician
Plastic Surgery
ENT
Intensivist
Anaesthesia
Dermatology
NEUROSURGERY REFERENCE
FINDINGS :
GCS : E1M4VT
Pupils right – 4mm not reacting
left - 2 mm sluggish reacting
ADVISED :
Continue antibiotics and repeat CT- Brain which
showed same report
OPHTHALMOLOGY REFERENCE
FINDINGS :
Right eye :
Traumatic mydriasis
Traumatic optic neuropathy
Right eyelid ecchymosis
Mild subconjunctival haemorrhage
Right lateral wall orbital fracture
ADVISED :
Moxicip eyedrops 4 times a day
Relub eyedrops 4 times a day
Inj methylprednisolone 1gm iv slow infusion for
3 days
Then
Tab wysolone 1mg/kg/day for 11 days
OMFS REFERENCE
FINDINGS :
Extra oral examination reveals facio
zygomatic slip
ADVISED :
No active intervention
RESPIRATORY MEDICINE REFERENCE
FINDINGS :
RS clear
HRCT normal
ADVISED :
No active intervention
RESPIRATORY MEDICINE REVIEW
FINDINGS : 5/5/15
Pt intubated on T-piece
SpO2 91% with T-piece
Bilateral crepts present
Bilateral conducted sounds present
ADVISED :
Repeat chest x-ray
Repeat routine investigations
Send ET aspirate for culture and sensitivity
Stop inj Zoact and start inj Tazar 4.5gm 1-1-1-1
PHYSICIAN REFERENCE
FINDINGS :
Unconscious
Not responding to deep pain stimulus
ADVISED :
Stop dynapar inj
S calcium, s. sodium, s. potassium, s. albumin
PLASTIC SURGERY REFERENCE
FINDINGS :
They did bedside debridement
Applied comfeel dressing for pressure sores at back and
shoulder
ADVISED :
Hourly change of position
Cushioning for knee and shoulder
No supine position
Protein powder in milk 1-0-1
ENT REFERENCE
FINDINGS :
No active bleeding present from nose and ear
ADVISED :
Continue same treatment
INTENSIVIST
FINDINGS :
Pt with polytrauma and head injury
GCS – E1M4VT
SpO2 – 98% on T-piece
ADVISED :
3% NS 100 ml/hr
NS/DNS 100 ml/hr
RBS 6 hrly
RT feeds 200ml 3 hrly
Noradrenaline @ 4ml hrly ---From 5th day
ANAESTHESIA REFERENCE
ADVISED :
ET care
Eye care
Inotropes as per physician advise
Neurology opinion for fitness for surgery
DERMATOLOGY REFERENCE
FINDINGS :
Multiple tiny pustules over erythematous base on left side
neck
Hypermigmented plaques present over the abdomen,
back and groin
Eczema with secondary infection ??, acute generalized
exanthematous pustules on neck, milliaria pustulosa
ADVISED :
Nadibact cream 1-0-1 L/A
Treatment was continued
Patient developed fever 102⁰F on 4th Day and became afebrile after 2 days after giving paracip iv
Central venous line was inserted at right internal jugular vein on 6th Day
Patient vitals were stable, input output was normal but bilateral crepts were present and GCS remained same
Regular dressings were done
Blood culture report showed staph aureus
sensitive to vancomycin, linezolid and
clindamycin on 5th day
Culture sensitivity report showed
enterococcus faecalis sensitive to
ampicillin, levofloxacin on 5th day
Accordingly antibiotics were started
Patient turned hypokalemic (2.82 meq/l) on 9th
day so she was started on 3 ampules KCl in 100
ml
Again patient developed fever 100⁰F on 11th day therefore urine culture was send and bladder wash was given
Physiotherapy was started from first day, chest and vibrations and percussions were given at upper lobe and suctioning with soda bicarb was performed
Upper limb passive movements were given
X-RAY CHEST
Patient was posted for surgery on
14/05/2015
Surgical fitness was obtained by
all the concerned departments
Consent was taken for grave risk
surgery and tracheostomy
Retrograde nailing was done for shaft femur fracture
and DHS was put for IT fracture under general
anesthesia
Tracheostomy was also performed
Patient underwent the procedure well
Same treatment was continued postoperatively with
regular dressings and care and 1 pint blood was
transfused
Intensivist advised repeat urine culture and blood culture for fever 100⁰F on 15/5/15 and change central
venous line, also advised to stop inj Tazar and start
Meromac plus 1.5gm 1-1-1
POST OP X-RAY
Central venous line was now put into left internal jugular vein on 16th day
Pus discharge was present from site where central line was put on right side, therefore linetip was send for culture, also discharge was present at operative site which was send for culture too
Since pt turned hypokalemic again (3.45 meq/lit), KCl was started 2amp in 100 ml NS for 4 hours
RT feeds were given, regular dressings were done sypkesol started, high protein diet given, auximen 7% started, regular suctioning was done for tracheostomy tube, regular investigations and monitoring were also done
URINE AND CULTURE SENS. REPORT
No organisms were grown in urine culture as on 16/5/15
Pus Culture sensitivity report showed serratia marcescens
sensitive to amikacin and some 3rd generation
cephalosporins on 18th day
Culture report was sensitive to Inj Amikacin and
Levofloxacin so both were started on 19th day and rest all
antibiotics were stopped
Physiotherapy was continued and all references were frequently reviewed
Tracheostomy tube was changed after 5 days
Patient had fever with chills on 21st day and was advised iv paracip 100 ml
1 pint PCV was transfused
S. Procalcitonin – 11.18 ng/ml
Urine osmolality – 404 mOsm/kg
Urine sodium – 91
Fever was 103⁰F on 23rd day and urine culture was sent and bladder wash was given
Patient fever subsided, vitals were stable so neurosurgery opinion was asked to shift the patient to ward on 25th day
Inj clexane 20 mg sc was started 0-1-0
Patient developed cerebral salt wasting secondary to head injury and 3% Na was started at 10 ml/hr with daily electrolytes and dietician was referred for high Na diet
BLOOD, URINE AND CULTURE SENS. REPORT
Blood culture showed klebsiella pneumoniae sensitive
to Amikacin and levofloxacin as on 22nd day
No organisms were grown in urine culture as on 22nd
day
Peripheral smear showed dimorphic anaemia with
neutrophilia
Patient was started with fludrocortisone 0.1mg daily
Permission to shift out the patient from ICU was taken from all the concerned departments on 26th day
Inj vancomycin 1 gm in 100 ml and inj cetil 1.5 gm iv 1-0-1 was advised
But physician advised to prolong the stay in ICU and stop levoflox and start Amikacin 750 mg
S. sodium was 129 and s. potassium was 6.52 meq/l on 27th day
Hydrocortisone 50mg 1-1-1 was started
Culture sensitivity report showed
acenitobacter baumanni and ac.
haemolyticus resistant to all on
28th day
S. lactate – 4.9 mmol/lit
On 29/05/2015 at 11:00 am :
Patient started gasping
Respiratory rate was 44 /min
BP – 90/60 mmhg
Started on noradrenaline/ dobutamine
Patient was put on SIMV
SpO2 – 99%
1 pint PCV was transfused
ECG was taken
Chest x-ray advised stat
Arterial blood gas analysis was done
Left subclavian central line was inserted
CHEST X-RAY
At 12:30 pm :
Patient continued gasping
BP was 70/40 mmhg
regular suctioning was done
At 2:20 pm :
Patient went into sudden cardiac arrest
BP was not recordable
Pulse – 144/min
Inotropes were increased to 15 ml/hr
Inj atropine given
CPR started
AMBU started
Inj adrenaline given
SpO2 not maintaining
At 2:30 pm :
BP and PR not recordable
SpO2 not maintaining
CPR continued
AMBU continued
Inj atropine repeated
Inj adrenaline repeated
At 2:45 pm :
BP and PR not recordable
SpO2 not recordable
CPR continued
AMBU continued
Inj atropine repeated
Inj adrenaline repeated
Pupils bilaterally dilated and fixed
At 3:00 pm :
BP and PR not recordable
SpO2 not recordable
CPR continued
AMBU continued
Inj atropine repeated
Inj adrenaline repeated
Pupils bilaterally dilated and fixed
At 3:15 pm :
BP and PR not recordable
SpO2 not recordable
Pupils bilaterally dilated and fixed
CVS – no heart sounds
RS – breath sounds absent
ECG shows flat line
Defibrillation attempted but patient did
not revive
Inspite of all resuscitation measures
patient could not be revived & patient
declared dead at 3:15 pm on 29/05/15 at
KLE Hospital, Belagavi
CAUSE OF DEATH
Immediate cause : septicaemic shock
Antecedent cause : fracture shaft femur
and intertrochanteric fracture right femur
and closed head injury