mortality meet in orthopaedics

1. PRESENTER- Dr. Saumya Agarwal
Junior resident Dept of Orthopaedics
J.N.Medical College and Dr. Prabhakar
Kore Hospital and MRC, Belgaum

2.  Name- ABC
 Age- 48 yrs
 Sex- Male
 IP No. – 123456

3.  Occupation- farmer
 Address- Mallur, Belagavi
 DOA - 11/02/15
 DOE - 12/02/15

4.  Pain and swelling over right thigh
 unable to walk
 since 10 days

5.  Patient was apparently alright 10 days
back, when he sustained a fall while
boarding the bus.
 After fall he complains of pain and
swelling over right thigh
 Pain was dull aching in nature and
continuous throughout the day and
swelling was localized to the right thigh

6.  After the accident he was taken to a
local hospital where x-rays were
taken and was referred to KLE for
further management
 No history of
 loss of consciousness
 ENT bleed
 seizures
 vomiting
 fever

7.  Patient is a known case of diabetes
mellitus since 16 years and is on
glimipiride twice daily
 Patient is a known case of
hypertension since 16 years and is
on amlodipine 25 mg twice daily
 No history of IHD/TB/Asthma

8. Diet – mixed
Appetite – not decreased
Sleep - Disturbed due to pain
Bowel & Bladder - regular
No addictive habits

9.  Not Significant

10.  Patient is moderately built and nourished
 Conscious and oriented to time, place and
person
 Pallor present
 No Icterus
 Clubbing
 Lymphadenopathy
 Edema
 Cyanosis.

11.  Temperature- Afebrile
 Pulse – 88/min
 Blood pressure- 126/80 mmhg
 Respiratory rate – 24/min

12.  CVS - S1 and S2 heard, No murmurs
 RS - Air entry equal on both the sides
 P/A - Soft, no organomegaly, bowel
sounds heard
 CNS – conscious, oriented

13.  Glasgow Coma Scale E4V5M6
15/15
 Revised Trauma Score
GCS4 SBP4 RR4 12/12
 Pupils reactive to light

14.  Patient was lying in supine position
 Attitude of the right lower limb was
externally rotated and abducted
 Cannot walk

15.  Swelling was present over right
thigh
 No engorged veins or sinuses
 No visible pulsations

16.  Inspectory findings are confirmed
 No local rise of temperature
 Tenderness present over right thigh
 ROM of right hip and knee – restricted
and painful

17.  Pelvic compression test positive
 Chest compression test negative
 No limb length discrepancy
 B/L Peripheral pulses well felt
 Toe movements were present

18.  Patient was admitted in general ward
on 11/02/2015 at 10 am
 Vital signs were stable
 Skin traction given
 Investigations send
 Treatment started

19.  Hb - 9.1 gm%
 WBC - 5000/cmm
 Differential count – N68, L27, E02, M03, B00
 ESR – 56 mm
 PCV – 25 %
 Platelet Count - 2.50 lakhs/cmm
 RBC - 2.70 millions/cmm

20.  Blood Urea – 32 mg/dl
 S. Creatinine - 1.0mg/dl
 S. Sodium - 144meq/l
 S.Potassium - 4.0meq/l
 S.Uric acid -5.5mg/dl
 Blood group – B +

21.  Inj Rantac 2cc iv 1-0-1
 Inj Inac im 1-0-1
 Tab Calcium 500 mg 1-0-0
 Cap Becosules 0-0-1

23.  Patient was posted for surgery
on 13/02/2015
 Surgical fitness was obtained by
physician on 11/02/15 in the
afternoon
 Chest x-ray was advised

24.  On 11/02/2015 at 5 pm :
 Patient started complaining of mild
discomfort in breathing
 Respiratory rate was 29 /min
 Salbutamol nebulisation was started
 Patient was given O2 at 3 lit/min
 Patient felt better and relieved
 No fresh complaints

25.  On 11/02/2015 at 8 pm :
 Patient complaint of chest pain and difficulty
in breathing
 BP was 100/70 mmhg
 SpO2 was 92%
 Pulse was 88 /min, Resp. rate was 32 /min
 Patient was given propped up position

26.  Salbutamol nebulisation given
 O2 started at 3 lit/min
 On duty physician was informed
 He advised to shift the patient to
ICU
 Patient was immediately shifted to
ICU

27.  Meanwhile, patient was on oxygen at 3
lit/min
 Arterial blood gas analysis and serum
electrolytes were sent
 Patient was maintaining saturation at 90%
 Pulse, BP , RR monitoring was going on half
hourly
 Chest x-ray was done
 ECG was done

28.  ABG showed metabolic acidosis with
compensatory respiratory alkalosis
 pH 7.17
 pCO2 26.8
 pO2 83.8
 HCO3 14.8
 S. Sodium - 142meq/l
 S. Potassium – 4.1meq/l
 S. Chloride 110meq/l
 ECG showed tachycardia with ST segment
elevation

30.  At 12 am :
 Pulse was 94 /min
 BP was 100/74 mmhg
 Respiratory rate was 33/min
 SpO2 86%
 Salbutamol nebulisation repeated
 with O2 continuing at 3 lit/min

31.  At 2 am :
 Patient started gasping
 Pulse was not recordable
 BP not recordable
 CPR started

32.  Inj.Atropine 2cc iv given
 Inj. Adrenaline 1mg iv given
 Patient intubated with
endotracheal tube

33.  At 2:15 am :
 Pulse was not recordable
 BP not recordable
 CPR continued
 Inj.Atropine 2cc iv given
 Inj. Adrenaline 2cc iv given

34.  Pupils became dilated, fixed and non
reactive to light
 CVS – S1 S2 absent
 RS – breath sounds absent
 ECG – no voltage
 Defibrillation attempted but patient did
not revived

35.  Inspite of all resuscitation measures
patient could not be revived & patient
declared dead at 2:30 am on 12/02/15
at KLE Hospital, Belgaum
 Post mortem was advised but patient
attenders refused.

36.  Immediate cause : Cardio – pulmonary
arrest secondary to pulmonary
thromboembolism ??, diabetes mellitus
and hypertension
 Antecedent cause : fracture shaft femur
right side