mortality case discussion

1. JAVAID AHMAD
SR CARDIOLOGY
AIIMS , New Delhi.
27-02-2018

2.  Mrs. ABC, 65/F
DOA- 25/02/2018
12: 00 AM
DOD- 25/02/2018
11:00 AM

3. Background history
Recently diagnosed as
 RHD- Severe MR, mild AR,Severe PAH, Mild LV
dysfunction, EF 50%.
 AF with LBBB (CVR)
 NYHA III.
 Was seen in OPD one week back and started on
metoprolol 25mg od , glyceryl mononitrate 30 mg SR,
enalapril 2.5mg, warfarin 3mg.
 Complained of general weakness- since 7 am in the
morning.
 Sought no medical help initially

4.  Presented to ED AIIMS at 11:15 Pm
Initial clinical exam:
concious, disoriented
Pulse 36/min, BP 76/50, RR 36/min, SpO2 88% on
ambient air
Chest- B/L vesicular breath sounds. Crepts (R) ISA
CVS- S1, S2 normal, systolic murmrer at apex

5. ECG in ED

6. VBG on presentation

7. CXR in ED

8.  Patient was intubated in ICU and started on
Isoprenaline and Noradrenaline infusion.
 Shifted to cath on venti for TPI.

9. Post TPI ECG

10.  Post TPI patient continued to be in shock, on triple
inotropes- adrenaline, Noradrenaline and Dopamine.
 Echo- severe MR,Mild LV dysfunction EF 50%
Hb 10.2g/dL
TLC 14800/mm3
DLC N80% L12%
Urea 55 mg/dL
Creatinine 2.8 mg/dL

11. Down Hill Course continued in CCU
 Patient continued to deteriorate
 Patient received inj Augmentin and Inj Levofloxacin.
 Inotropic drug requirement continued to increase
 In the morning at arround 10 am patient developed
cardiac arrest, monitor revealed asystole, pacing spikes
with no capture.
 CPR was given for about 30 mins and patient was
declared dead at 11 am.

12. Final diagnosis
 Refractory cardiogenic shock with severe bradycardia-
CHB with Ventricular escape rythm
 ?Septic Shock
Source ? chest
 ?Drug toxicity
Beta blocker/ Nitrates

13. Could it have been better managed????
 Was medical therapy in OPD over-aggressive since
such patients have no monitoring at home????
 Could it be sepsis on top of cardiac disease????
 Should we have tried inj Glucagon????
 Or was it very late presentation as she presented with
severe lactic acidosis!!!!
 Was it terminal bradycardia!!!!!

14. Every death should make us think!!!!!!