death review

1. Death Case Review
By
UNIT 1- Department of General Medicine
MGM Medical College & LSK Hospital,
Kishanganj, Bihar

2. 48 years old Female presented in Casualty on April 17th at 02:23 PM with chief
complaints of
● Right sided chest pain since 1 day
● Shortness of breath since 1 day
● Generalized body weakness since 1 day
History of similar complaints present for last 5-6 years; The symptoms
exaggerated since 1 day.

3. PAST HISTORY
● Known case of ?Chronic Obstructive Pulmonary Disease on irregular
medication from TB and chest department. (History of Chronic Smoking: ~ 20
pack’s years; Irregular use of inhaler )
No documentation available with patient party.
With these complaints, unstable vitals and after clinical examination, Patient was
advised admission in ICU.

4. In the Emergency room
Patient was semi–conscious, drowsy,not-oriented to time place and person.
Vitals=> GC- Poor
Pulse- 90beats/min
Blood Pressure- 80/50 mm Hg
SpO2- 70% at Room Air
RR- 22/min
Temp- 99.8*F
RBS- 104 mg/dL
On Examination
CNS- Patient semi conscious, drowsy,
not oriented to time, place and person
• B/L Pupil Reactive
• B/L Plantar Flexor
• No Signs of meningeal
irritation
CVS- S1,S2 audible, No added sounds
Per-Abdomen - Soft, non – tender,
Bowel sounds heard
… Continued

5. Examination (continued…)
CHEST-
On Inspection: Accessory Muscles Active, Thoraco-abdomino type of Respiration
On Palpation: Trachea central, chest movement reduced right sided, increased tactile fremitus over Right
inframammary zone
On percussion: Dull note heard over right inframammary and infra axillary region Region
On Ausculatation: B/l Air entry present with Bilateral wheeze present, crepts present (Right >> left sided)
ABG, ECG, and CXR-P/A view were advised urgently but the patient party was non compliant on
investigations.
PBS with Retic count, LFT, RFT, FBS, PPBS, HbA1c, S.Ferritin, Lipid profile, Urine C/S, Blood C/S,
CPKMB, LDH, 2D-ECHO, Sputum for AFB, C/S, CB-NAAT, S. Procalcitonin were advised.
(Patient party was non compliant on investigations)

6. ABG, ECG, and CXR-P/A view were advised urgently but the patient party was non compliant on
investigations.
PBS with Retic count, LFT, RFT, FBS, PPBS, HbA1c, S.Ferritin, Lipid profile, Urine C/S, Blood C/S,
CPKMB, LDH, 2D-ECHO, Sputum for AFB, C/S, CB-NAAT, S. Procalcitonin were advised.
(Patient party was non compliant on investigations)
ABG @ 6:15 P.M.
pH- 7.22
pCO2- 39 mmHg
pO2- 42 mmHg
HCO3- 16.0 mmol/l
Lac- 4.2 mmol/l

7. Treatment in Emergency room
- IV access secured
- Continuous moist oxygen inhalation @ 8-10 lit/min
- Inj ondansatron(4mg) i/v stat
- Inj Pantoprazole(40mg) i/v stat
- Inj Hydrocort 100mg i/v stat
- Inf. 2 units – normal saline 0.9% in jet
- Nebulization with Duolin and Budacort stat
- Patient was admitted in ICU with proper high risk consent and after explaining poor prognosis
to patient party.

8. Advice at the time of admission
- Inj Piperacillin+Tazobactam(4.5 gm) I/V thrice daily after test dose and skin testing
- Inj Levofloxacin (500mg) I/V once daily after test dose and skin testing
- Inj Linezolid (600mg) I/V twice daily after test dose and skin testing
- Inj Pantoprazole(40mg) i/v twice daily
- Inj Ondensatron(4mg) i/v twice daily
- Nebulization with Duolin x 4th hourly
- Nebulization with Budacort x 6th hourly
- Continuous moist oxygen inhalation @ 6 litres/minute
- CPAP mode of ventilation @ 5cm H2O, secure airway with guedels airway

9. Advice at the time of admission
- IVF 0.9% Normal Saline 4 Units @ 100ml/hr
- Inf. Noradrenaline 2 amp in 46ml NS@ 4ml/hr( Taper accordingly and inform DOD)
- Monitor vitals(PR/BP/SPo2/RBS/ Temp) Second hourly
- Keep patient in Left Lateral Position

10. At 21:00 PM on 17/04/23, distress call received by doctor on duty
Vitals: BP: 60/50 mmHg @ Norad 4ml/hr
Pulse: 106bpm
SpO2: 100% @ CPAP mode of ventilation
O/E: Chest: Bilateral wheeze +, crepts +
CVS: S1S2 audible, no added sounds
CNS: Restless
Advice:
1. Inj Dobutamine 2 ampules in 40 ml NS @ 6ml/hr
2. Increase Noradrenaline to 9ml/hr
3. Plan for intubation and vasopressin infusion after proper consent
*Patient party non compliant to
investigations and treatment*

11. At 12:00 AM on 18/04/23, distress call received by doctor on duty
Vitals: BP: 60/40 mmHg @ Norad 9ml/hr and dobutamine @ 6ml/hr
Pulse: 120bpm
SpO2: 100% @ CPAP mode of ventilation
RBS: 250mg/dl
Urine output: 150 ml in over 4 hours
O/E: Chest: Bilateral wheeze +, crepts +
CVS: S1S2 audible
CNS: Altered sensorium, drowsy
Advice:
1. Increase Dobutamine to 10ml/hr
2. Increase Noradrenaline to 12ml/hr

12. At 3:00 AM on 18/04/23, distress call received by doctor on duty
Vitals: BP: 60/40 mmHg @ Norad 12ml/hr and dobutamine 10ml/hour
Pulse: 118 bpm
SpO2: 100% @ CPAP mode of ventilation
RBS: 231 mg/dl
O/E: Chest: Bilateral wheeze +, crepts +
CVS: S1S2 audible, no added sounds
CNS: Altered Sensorium, drowsy
Advice:
1. Increase Dobutamine to 12ml/hr
2. Increase Noradrenaline to 15ml/hr

13. At 07:15 AM on 18/04/23, distress call received by doctor on duty
Patient’s vitals were non recordable
CPR was started as per ACLS protocol
B/L pupils were dilated and fixed
ECG showed no Cardiac activity
Patient was declared clinically dead at 08:00 AM

14. Cause of death
Immediate cause: Septic shock with Type IV Respiratory failure
Antecedent Cause: ?Right lower lobe pneumonia
Others: Chronic Obstructive Pulmonary Disease

15. Thank You