mortality meet presentation by dr. saumya agarwal

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