CASE PRESENTATION DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE 1 - PowerPoint PPT Presentation

CASE PRESENTATION DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE 1

CHIEF COMPLAINTS Pt brought to the EMD with complaints of 1)shortness of breath since 1 day 2)fever since 3 days 2

VITAL SIGNS Pulse rate 119/min Blood pressure 110/60 mmHg Respiratory rate 24/min Temperature 100 F Pain nil SPO2 82% WITH RA(0.2) GRBS 252 mg/dl ON ARRIVAL GCS E4 V5 M6 3

PRIMARY SURVEY UNABLE TO SPEAK AIRWAY FULL SENTENCES TACHYPNEIC 02 SATURATION : 82% BREATHING WITH RA (FiO2 : 0.2) NO CYANOSIS NORMOVOLEMIC ( BP 110/60 MMHG) CIRCULATION CAPILLARY REFILL TIME (<3 SEC) 4

HISTORY • A 55 yr old female,housewife,resident of Nakrekal village brought to the EMD with complaints of shortness of breath since 1 day, grade III, sudden onset,associated with B/L pedal edema since 3 days and decreased urine output since 1 day. • No history of chestpain,palpitations,syncope, orthopnea . • No history cough, noisybreathing,expectoration. 5

• History of fever, high grade with chills and rigor associated with burning micturition and dysuria and incresed frequency since 3 days. • And mild abdominal pain,diffuse in nature not associated with vomiting,diarrohea or abdominal distension . 6

• Past medical illness : K/C/O of type 2 diabetes mellitus(NIDDM). • Past surgical illness : History of right great toe amputation(? Diabetic foot) • Medications : Using METFORMIN 500 mg BD • Family history : Not significant 7

Secondary survey General : Conscious, unable to lie comfortable on bed due to distress . Head: Atraumatic,normocephalic Eyes: Normal size pupils reacting to light,no pallor ,no icterus Ears: Normal tympanic membranes Nose: No discharge 8

Secondary survey Neck: jugular venous distension present, no stridor,no cervical lymphadenopathy Pharynx: Tongue dry, normal dentition, no lesions,no swelling Chest: B/L symmetrical,non tender, no deformity. Lungs: B/L air entry equal,no added sounds 9

Secondary survey Heart: Tachycardia (119/min), rhythm regular, no murmurs, no rubs, or gallops. Abdomen: Diffuse abominal tenderness with right flank predominant tenderness with right costovertebral angle tenderness present ,no mass felt ,no guarding or rigidity. Urogenital: Burning micturition present ,decreased urine output, no discharge. 10

Secondary survey Extremities: Normal pulses, no neuro deficits. Back: Right costovertebral angle tenderness present Neuro: Normal sensation, strength; normal reflexes and gait, Skin: Normal Lymphatic system: No generlized/local lymphadenopathy. 11

DIFFERENTIAL DIAGNOSIS 12

K/C/O NIDDM,HIGH SUGARS,DYSPNEA DIABETIC KETOACIDOSIS ? UTI/PYELONEPHRITIS,MILD ABDOMINAL PAIN CONGESTIVE CARDIAC DYSPNEA,B/L PEDAL EDEMA, RAISED JVP,K/C/O NIDDM,TACHYCARDIA FAILURE(CORPULMONALE) K/C/O NIDDM,BL PEDAL EDEMA, ACUTE/CHRONIC KIDNEY INJURY DECREASED URINE OUTPUT SUDDEN ONSET DYSPNEA,B/L LIMB ACUTE PULMONARY EMBOLISM SWELLING,TACHYCARDIA,CLEAR LUNGS FEVER,BURNING MICTURITION,ABDOMINAL PAIN, UROSEPSIS COSTOVERTEBRAL ANGLE TENDERNESS,INCREASED (UTI/ACUTE PYELONEPHRITIS) FREQUENCY,TACHYCARDIA 13

INVESTIGATIONS ECG USG ABDOMEN ABG URINE FOR KETONES CHEST X RAY HIV,HBsAG,HCV 2D ECHO HbAIC CBP RBS RFT LFT BLOOD GROUPING CUE LOWER LIMB DOPPLER BLOOD AND URINE C/S COAGULATION PROFILE 14

ECG 15

• After initial ECG showing sinus tachycardia and S1Q3T3 pattern. • Pt been advised for SPIRAL CT with pulmonary angiography, D dimers. 16

Event analysis (16/12/2017,1;20am) • Patient developed severe respiratory distress after shifting from CT room. • In the view of respiratory failure patient is intubated with endotracheal tube 7.5mm, cuff inflated and after confirming B/L air entry equal with five point auscultation fixed at 22 cm lip mark. 17

• And connected to mechanical ventilator with initial settings • MODE : IPPV • FREQUENCY : 16/MIN • FIO2 : 100 % • TIDAL VOLUME : 400 ML • PEEP : 0 CM H20 18

EVENT ANALYSIS(16/12/2017,1:40 AM) • Pt ECG monitor suddenly showing no electrical activity with absent central and peripheral pulses , so immediately CPR initiated according to ACLS 2015 guide lines. • After 6 min of CPR (each cycle 30 compressions plus 2 rescue breaths) plus inj adrenaline intra tracheal ) patient achieved ROSC with PR : 124/min, blood pressure 100/50 mmHg,SPO2 95% ) 19

Post CPR care : 1)IV fluid bolus @ 20 ml/kg 2)Inj. MANNITOL 1gm/kg iv stat 3)Inj. DOBUTAMINE 5 mic/kg/min continous infusion. 20

Event analysis(16/12/2017,2:00 am) Narrow complex tachycardia with absent P waves regular rhythm Supraventricular tachyardia noticed 21

• ECG showing supraventricular tachycardia with hemodyanmic unstability. • So immediately cardioversion with 50 J given. • Rhythm reverted back to normal sinus tachycardia. 22

Investigations(day of admission) CBP Coagulation profile Hb 9.3gm/dl PT 19 sec WBC 40,000/cumm INR 1.45 platelets 1.52 APTT 39 sec lakhs/cumm Blood group O/ Rh positive HBA1C 7.6% 23

ARTERIAL BLOOD GAS ANALYSIS PH 7.34 PCO2 22 PO2 112 HCO3 11 BE -12 Metabolic acidosis with compensatory respiratory alkalosis 24

Investigations(day of admission) RENAL FUNCTION TESTS LIVER FUNCTION TESTS Total 1.58 mg/dl Blood urea 104 mg/dl bilirubin Serum 2.2 mg/dl Direct 0.59 mg/dl creatinine bilirubin Na 119 mmol/l SGOT 81 IU/L K 4.5 mmol/l SGPT 60 IU/L Cl 81 mmol/l ALK 274 IU/L PHOSPHATE ALBUMIN 2.8 gm/dl 25

Urine examination SG 1.010 Urine for ketones - PH acidic negative SUGARS ++++ ALBUMIN + HIV NONREACTIVE COLOUR Pale yellow BILESALTS/ Absent/negati HBSAG NON REACTIVE PIGMENTS ve PUS CELLS 15-16 HCV NON REACTIVE CASTS/ nil CRYSTALS 26

2D ECHO : • Right atrial and ventricular dilatation. • IVC disteneded • OS ASD • Good LV function • EF : 58% USG ABDOMEN : emphysematous pyelonephritis right kidney LOWER LIMB DOPPLER : NORMAL STUDY D DIMERS : 200 -400 ng/ml 27

CHEST X RAY 28

CT CHEST 29

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CT ABDOMEN 34

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Final(complete) diagnosis • Empysematous pyeloneorhitis with septic shock • Venous gas embolism with respiratory failure. • With acute kidney injury(AKI) • K/C/O type 2 diabetic mellitus • Ostium Secundum 38

PROBLEM BASAED APPROACH I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK II. VENOUS GAS EMBOLISM WITH RESPIRATORY FAILURE III. ON MECHANICAL VENTILATION IV. AKI ( SECONDARY TO PYELONEPHRITIS) V. COAGULOPATHY VI. HYPONATREMIA(? Hypovolemic hyponatremia) VII.K/C/O OF TYPE 2 DIABETES MILLITUS VIII.POST CPR STATUS 39

I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK 1.INJ.IMIPENEM CILASTIN 500MG IV BD 2.INJ.LEVOFLOXACIN 500MG IV BD 3.CENTRAL VENOUS ACCESS SECURED 4.INJ .NORADRENALINE 0.02MIC/KG/MIN WITH TARGET MAP >65 MMHG 5.Urology consulation done. 40

II&IIIVENOUS AIR EMBOLISM WITH RESPIRATORY FAILURE 1.OXYGEN THERAPY WITH INVASIVE RESPIRATORY SUPPORT 2.INJ.UNFRACTIONED HEPARIN 5000 IU SC QID 3.VENTILATORY SETTINGS MODE : IPPV FREQUENCY : 16/MIN FIO2 : 80 % TIDAL VOLUME : 400 ML PEEP : 0 CM H20 41

IV. AKI ( SECONDARY TO PYELONEPHRITIS ) • MAINTAIN TARGET MAP >65 mmHG • MONITOR URINE OUTPUT /HOUR • INJ. FURESOMIDE 20 MG IV BD IF MAP >65 MMHG • NEPHROLOGIST OPINION AND PLAN FOR HEMODIALYSIS IF SYMPTOMS WORSENS. V.COAGULOPATHY(DIC) • 3 units FRESH FROZEN PLASMA infused. 42

VI. TYPE 2 DIABETES MELLITUS(NIDDM) • INJ.HUMAN ACTRAPID (ALBERTS REGIMEN: GIK REGIMEN) • GRBS MONITORING EVERY 4 TH HRLY VII. POST CPR STATUS • SUPINE POSITION,HEAD NEUTRAL & FLAT • TEPID SPONGING AND AVOID HYPERTHERMIA • IV FLUIDS 0.9 NS @ URINE OUTPUT PLUS 50ML/HR • INJ DEXAMETHASONE 4MG IV TID 43

• INJ.RANITIDINE 50MG IV BD • INJ.ONDANSETRON 4MG IV SOS • Rt feeds @25 kcal/kg/min (100 ml/hour 2 nd hrly) • Regular ET/ORAL suction 2 nd hrly • Position change 2 nd hrly • Limb and chest physiotherapy • With contnous monitoring of HR,MAP,URINE OUTPUT,SPO2,TEMPERATURE. 44

DAY 2 (17/12/2017) • Patient on mechanical ventilator with GCS E4 VT M6 • On mechanical ventilatory support VITAL SIGNS Pulse rate 114/min Blood pressure 110/60 mmHg Respirate rate 16/min ON M.V. Temperature 99 F 45

INVESTIGATIONS(DAY 2) Liver function tests Renal function tests Total 5.94 mg/dl Blood urea 131 mg/dl bilirubin Serum 3.2 mg/dl Direct 3.79 mg/dl creatinine bilirubin Na 129mmol/l SGOT 184IU/L K 3.9 mmol/l SGPT 122 IU/L Cl 93 mmol/l ALK 225IU/L PHOSPHATE ALBUMIN 2.9gm/dl 46

PROBLEM BASAED APPROACH (DAY 2) I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK II. VENOUS AIR EMBOLISM WITH RESPIRATORY FAILURE III. ON MECHANICAL VENTILLATOR IV. AKI ( SECONDARY TO PYELONEPHRITIS) V. HEPATOCELLULAR DYSFUNCTION VI. K/C/O OF TYPE 2 DIABETES MILLITUS VII.CRITICALLY ILL /ICU CARE 47