202113662

Case History and Clinical Findings:

69 year old male chronic smoker since 40years and alcoholic since 20 years known case of hypertension sine 5 years was apparently asymptomatic 5 years back until he had sudden onset chest pain and SOB for which he was taken to a hospital in hyderabad where he was told to be having some heart problem and symptomatic treatment was given (no records are available).

patient was completely asymptomatic from then in the past 5 years until last night when he had low grade fever and 2 episodes of vomiting after alcohol intake. 

From 16/6/21 morning he had pain abdomen,abdominal distention ,SOB and drowsiness. 

Patient came to the casuality in a state of drowsiness with pain abdomen ,distension ,SOB and generalised weakness. 

O\E: Pt drowsy but arousable , coherent and cooperative 

JVP raised

PR: 78bpm 

BP:110/70 mm hg 

SpO2:98% on RA 

CVS: s1,s2heard 

RS:BAE + , NVBS , Fine crepts + in Right IAA & ISA

P/A: soft,distended 

CNS: NFND



30 min later GCS worsened 

Feeble peripheral pulses 

BP: systolic 50 mmhg on palpation

CVS: s1,s2 muffled 

RS: BAE + , NVBS

P/A: soft, distended, sluggish bowel sounds heard, no guarding / rigidity 

CNS: NFND


Investigation:

HB : 11.5 

TLC 29,700 

PLATELETS : 1.85 

PT : 17 

INR :1.2 

APTT :33 

UREA : 44 

CREATININE : 1.3

Na+ - 135 

k+ - 4.1 

Cl- 98 


X-RAY CHEST-PA:



X-RAY ABDOMEN-SUPINE:



ECG:




TROPONIN I- NEGATIVE 


2D ECHO: 



The mid posterior (aka inferior) segment representing the RCA is akinetic while rest of the walls are hypokinetic consistent with the ECG changes in inferior wall representing RCA supply and ST T changes in the lateral leads.

GLOBAL HYPOKINESIA 

DILATED LA/LV 

EF : 27% 

TR WITH MILD PAH + 

RVSP-40 mmhg

DIASTOLIC DYSFUNCTION + 

IVC : 1.35cms


DIAGNOSIS:

HFrEF SECONDARY TO ?CAD 

CARDIOGENIC SHOCK WITH REFRACTORY HYPOTENSION 

RIGHT SIDED PNEUMONIA 

K/C/O HYPERTENSION SINCE 1.5 YEARS 


TREATMENT:

1)Nill by mouth till further orders 

2) IVF- 1 NS IV/bolus given; 0.9% NS continuous infusion U.0+30ml/hr 

3) Inj.NORADRENALINE 2amp in 48 ml NS @ 12 ml/hr (0.48 mg/hr)

4) Inj.DOBUTAMINE 1 amp (1ml=1000mcg) in 45 ml NS @ 4 ml/hr (20mg/hr) 

(increase or decrease according to MAP~65-70mmhg)

5) Inj.THIAMINE 1 amp in 100ml NS /IV/TID 

6) Inj.PAN 40mg/IV/OD 

7) Monitor BP, PR,RR 

8) STRICT I/O Charting 

9) Inj.AUGMENTIN 1.2gm/IV/BD 


Ryles tube insertion - aspirate bilious (100 ml)

Surgery referral was taken in v/o pain abdomen and abdominal distention.

DRE: anal spincter tone: normal, rectum loaded, gloved finger stained with fecal matter, 

Advised x-ray abdomen supine which came out to be normal.

So no active surgical intervention.


At 4:00 AM on 17/6/21 patient suddenly became unresponsive with no recordable PR/BP/SpO2. 

CPR was initiated acc. To 2015 AHA guidelines and patient was intubated with ET 7.0 

4:00AM BP/PR - NR- CPR Initiated, INJ ADRENALINE 1MG IV/ STAT 

4:05AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 

4:10 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 

4:15 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 

4:20 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 

4:25 AM BP/PR - NR - CPR Continued , INJ ADRENALINE 1MG/ IV STAT 

4:30 AM BP/PR - NR 

Despite of the above resuscitatiove measures patient couldn't be revived and declared dead at 4:37 AM on 17/6/21.


DEATH SUMMARY:

69/m came to casuality on 16/6/21 at 3:00  with c/o fever and 2 episodes of vomiting yesterday night f/b pain abdomen , sob (2-3) and altered sensorium since 16/6/21 morning.

Inotropes were started in v/o hypotention.

ECG showed non specific ST-T changes st elevations noted in Lead 2,3,AvF with reciprocal changes in Lead I,AvL,V5,V6.

2D ECHO : global hypokinesia , dilated LA/LV ,EF : 27% , TR with mild PAH + , RVSP-40

Troponin- I : negative 

Symptomatic treatment was given.

Surgery referral was taken in v/o pain abdomen and abdominal distention

Advised x-ray abdomen supine which came out to be normal.

So no active surgical intervention.

On 17/6/21 at 4:00 AM patient suddenly became unresponsive with no recordable BP/PR/SpO2.

CPR was initiated acc to 2015 AHA guidelines and continued for 6 cycles.

Despite of all the resuscitative measures, patient couldn't be revived and declared dead at 4:37 AM on 17/6/21.


IMMEDIATE CAUSE : 

CARDIOGENIC SHOCK WITH REFRACTORY HYPOTENSION

ANTECEDENT CAUSE : 

HFrEF SECONDARY TO ?CAD , RIGHT SIDED PNEUMONIA, K/C/O HTN

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