mr. ranganathan
TRANSCRIPT
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DEATH AUDITDECEMBER 2016Dr. Sujay IyerI Year PGGeneral Medicine Unit IV
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PATIENT DETAILS Name: Mr. Ranganathan Age/ Gender: 67 years/ Male MR number: 16/402110 IP number: 16/061538 DOA: 15/12/2016 at 18:54 DOD: 19/12/2016 at 01:30 Duration of Stay: 3 days
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PRESENTING COMPLAINT Patient was brought to the ER on 15/12/16 at
5 pm in an unconscious state with ET tube in-situ without any ambu-bag or ventilatory support.
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HISTORY OF PRESENTING ILLNESS Patient had sudden onset of loss of consciousness
after he complained of dizziness on 10/12/16 which resulted in a slip and fall.
H/O involuntary micturition (+) H/O deviation of angle of mouth to right side (+) H/O weakness of left upper and lower limb. He was taken to Manakulla Vinayagar Hospital
where he was diagnosed as right MCA territory infarct with hemorrhagic transformation after a CT scan brain was done (Large left fronto-parietao-temporal infarct with hemorrhagic transformation and significant midline shift)
He was intubated and ventilated due to poor GCS.
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HOPI Patient was treated with Mannitol,
Atorvastatin, Ceftriaxone and Dexamthasone. Outside investigations on 13/12/16:
Urea: 133; Creat: 4.43 TC: 18,900 2D ECHO: Inferior wall hypokinesia (+), LVH (+),
LVEF – 45%, CAD (+). Decompressive craniotomy was advised, but
since patient’s attenders were unwilling; patient was discharged against medical advice.
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HOPI Patient was taken to PIMS and East Coast
Hospital where the same advice was given, but since patient’s relatives were unwilling; he was discharged against medical advice and taken home.
He was kept at home for a day with ET tube in-situ.
On the afternoon of 15/12/16, patient started gasping and was brought to MGMCRI for further management
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PAST HISTORY K/C/O Systemic Hypertension and Type 2
Diabetes Mellitus since 4 years. On irregular medication
Not a K/C/O PTB, Seizure disorder, Bronchial Asthma.
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GENERAL EXAMINATION HR – 120/min BP – 80 systolic RR – 24/min SpO2 – 98% on room air with ET tube insitu Temp – 103*F GCS – 3T/15 CBG – 158 mg%
Patient was immediately mechanically ventilated by Critical Care team in Volume Control mode after airway suction was done.
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SYSTEMIC EXAMINATION R/S: NVBS (+). BAE (+). B/l conducted
sounds (+) CVS: S1S2 (+). No murmurs. P/A: Soft, non-tender, no organomegaly. CNS:
GCS - 3T/15. Unresponsive to painful stimuli. Left and Right UL and LL tone – Reduced. Bilateral plantars – Mute. Left pupil – Sluggishly reacting to light.
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INITIAL MANAGEMENT Patient was immediately started on Inj.
Dopamine at 5mcg/kg/min. Neurosurgery, Critical Care and
Ophthalmology opinions were sought. Neurosurgery consult was for nil intervention. Poor prognosis was explained to the patient’s
relatives. Patient was admitted under GM IV in the ICU.
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ECG
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CHEST X-RAY
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INITIAL INVESTIGATIONSPATHOLOGY BIOCHEMISTRY BIOCHEMISTRYCBC:Hb – 14.9TC – 13,900 (N: 80%)Plt – 96,000
URINE ROUTINE:Pus cells – (+)Bacteria – OccasionalSugar – (+)
ABG: pH – 7.45pCO2 – 37pO2 – 33HCO3 - 25
RFT:Urea – 32.9Creat – 6.7
ELECTROLYTES:Na – 143K – 4.6Cl – 107Ca – 8Ph – 4.8Mg – 1.5
LFT:T.P – 6.4Alb – 3.8T.B – 2.3D.B – 0.9
AST – 84ALT – 49AlkP - 75Amylase – 75GGT – 71PT – 16 (13.5)INR – 1.2PTT – 26 (32)
CARDIAC MARKERS:TROP I – (-)CPK T – 737CPK MB – 15
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INITIAL TREATMENT Inj. Piperacillin + Tazobactum 4.5g IV stat
then 2.25 g IV TDS. Inj. 3% NS IVF at 20 ml/hr. Inj. Pantoprazole 40 mg IV OD. Inj. Noradrenaline IVF at 1.3 ml/hr (Targer
MAP of 65 mmHg) Syp. Lactulose 30 ml TDS. Inj. Dopamine was tapered off.
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15/12/16 At 10 pm, patient was found to have a HR>
200/min on the monitor. ECG revealed SVT. Pulse was not felt. Patient was cardioverted twice with 50 J and
then once with 100 J. Patient reverted back to sinus rhythm. CVP line in subclavian vein was placed.
Arterial line was also placed.
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16/12/16 Patient was on PCV mode with Inj.
Noradrenaline. HR – 109/min. BP – 100/70. I/O – 2070/360. Unresponsive to deep painful stimuli. Nephrology opinion was sought in view of
requirement of hemodialysis for poor urine output.
Dr. Hemachander advised hemodialysis under high risk, patient’s relatives refused.
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17/12/16 Patient was on CPAP mode. Noradrenaline
had been tapered. HR – 85/min. BP – 130/70 mmHg. I/O –
4133/2175. Patient was started on Inj. Amiodarone IVF at
2.2ml/hr in view of frequent SVT. Patient’s hyperkalemia was corrected. Neurologically, patient continued to be in
status quo. Hyoptonia in all 4 limbs Right plantar – extensor. B/L pupils – sluggishly reactive.
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INVESTIGATIONS17/12/16 18/12/16
Urea – 99Creat – 6.5
Na – 149K – 5.0Cl - 117
Urea – 146Creat – 5.17
Na – 149K – 4.9K - 117
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18/12/16 Patient was on PCV mode. On Inj.
Amiodarone infusion. HR – 89/min. BP – 220/90 mmHg. I/O –
4428/2365. Patient was unresponsive to deep painful
stimuli. Neurologically deteriorating as pupils were
found to be dilated and fixed, not reactive to light.
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18/12/16 At 11 40 pm, patient was found to have HR >
200/min. Monitor showed Ventricular Tachycardia.
BP – 70/40 mmHg. SpO2 – 62% at 100% FiO2 at PCV mode.
Patient was given 2 cycles of defibrillation at 150 J.
CPR was initiated according to ACLS protocol. Patient continued to have VT despite 5 cycles
of defibrillation and Inj. Adrenaline. At 12 30 am, Inj. Amiodarone 150mg bolus
was given.
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19/12/16 At 12 45 am, patient developed SVT. Inj.
Adenosine was administered. At 1 am, patient went into bradycardia. CPR
was continued. At 1 25 am, patient went into asystole. Heart
sounds were absent. Despite all resucitative efforts, patient was
declared dead at 1 30 am.
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CAUSE OF DEATH Cerebrovascular Accident – Left middle
cerebral artery infarct with hemorrhagic transformation.
Systemic Hypertension. Coronary Artery Disease. Acute Kidney Injury. Acute on Chronic Kidney Disease.
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THANK YOU