4. Presenting complaint (26th/06/2023) SHO rv @ A&E
Left sided neck swelling x 3/12
HPC:
M.H, 47 Yr old male with no known chronic illness, came in c/o left sided
neck swelling x 3/12 which, had recently, rapidly increased in size x 3/52,
with associated inability to swallow solids, but could take fluids with
dysphagia;
Mass was associated with D.I.B, but No chest pain and no PND
No odynophagia, No Vomiting
Abdominal distention x 2/12 with associated pain in the L.L.Q
Repted nmal sft stool prior to admn with no melena & no hematemesis
5. Cont…
No Lower Limb Swelling.
Reports associated evening fevers, Night sweats, Loss of weight and
loss of appetite.
Unknown HIV status, No known chronic disease
No food or drug allergies;
PSHx. Unremarkable.
6. FSHX
h/o smoking cigarettes X 5 yrs (~ 3 sticks per day), but stopped the
smoking ~ 5/12 ago.
Reports drinking Alcohol ~ x 5 Yrs but stopped ~ 5/12 ago.
No clearly evidenced family hx for cancers.
O/E: sick looking, No pallor, No jaundice, Afebrile, Some dehydration,
Bilateral inguinal lymphadenopathy
temp 36.5o C, P -139, SPO2 – 96% on RA
7. R/S
RR - 30/min, Reduced air entry of the R lung base, with crepitations, Good
air entry in the L lung, with vesicular breath sounds.
P/A
Moderate distention, Mild tenderness in the lower abdomen
Dull percussion note with palpable masses in the lower abdomen.
No h/o Operation, had a tympanic note in all regions, Bowel sounds
absent.
DRE: Normal anal sphincter tone, rectum full with hard stool.
L/E: Noted a L side neck mass ~ 10x8 cm, firm, non-tender, fixed to
underlying tissues, No temp. differences or gradients
8. Dx
47/M with Lt side neck mass possibly lymphoma.
Ddx;infective (sialadenitis, Reactive lymphadenopathy).
PLAN
Admit pt to surgical ward and await biopsy.
DO CXR, RCT, CBC
IV paracetamol (1g 8hr)
IV Omeprazol 40mg OD
IV Morphin 7.5 mg
IV Ceftriaxone 2gm
11. 27/06/23 @ 04:00HRS SHO r/v
Noted all h/o 47/M admitted with ? Lymphoma for Biopsy
W.O.B
Associated with D.I.B and restlessness
O/E
sick looking temp 37C, No pallor, No Jaundice, BP – 136/70 mmHg,
SPO2 92% on 5L of O2 via NP , PR 170bpm
R/S.
Obvious chest distress with intercostal recessions
RR – 38/min, with equal air entry bilaterally with basal crepitations.
Dx 47/M ? P.E
Plan: S/c claxane 80IU stat, Change to NRM for O2 delivery and transfer to HDU
Inform Intensivist for possible transfer to ICU and give IV D50% 50ml Stat
14. 27/06/23 @ 04:30HRS SHO r/v
Intensivist was informed of the clinical status of the pt.
Found her ready with resuscitation of another pt and instructed NRM
for O2 delivery 10l will be coming for review
At 5am, found pt in obvious distress, gasping for air, PR less than
60bpm and started CPR
No defibrillator to assess rhythm.
No ROSC after one cycle
O/E
… Pupils fixed and dilated. Not reacting to light
15. R/S
No spontaneous chest mv’t.
No air entry
CVS
No pulse
No BP
Confirmed dead at 5:15 am
Cause of death, Cardiorespiratory arrest 2O to P.E
Condolence passed on to family.
16. Good points
Doctors were on duty including the SHO , nursing team & all
attended to the pt
ATLIST Timely interventions were done
17. Missed opportunities;
Pre-Hospital Factors Patient’s Factors System factors
Took long time Smoking and Alcohol
intake
Consultation and discussion with
seniors wasn’t done.
.failed to secure the airway in time.
Social-economic status
of pt.
Unknown HIV status Multidisciplinary approach was
lacking
Attitude / health seeking
behaviors
Timely investigations e.g Radiology
was not done
Failed to follow HDU / ICU
admission criteria.
.we managed Biopsy bt nt pt.
18. Case discussion:
INDICATIONS OF TRACHEAL INTUBATION
Airway obstruction is the clinical situation in which a patient develops signs or
symptoms due to narrowing or ? distortion of the airway
The most common indications include;
Acute respiratory failure
Inadequate oxygenation / ventilation
Definitive airway protection in a patient with depressed mental status.
Administration of some drugs e.g. surfactant, adrenaline
In the perioperative setting;
• Patients receiving general anesthesia
• Surgery involving or adjacent to the airway
• Unconscious patients requiring airway protection
19. CONTRAINDICATIONS OF TRACHEAL INTUBATION
Absolute contraindications include;
Blunt trauma to the larynx
Penetrating trauma of the upper airway e.g. hematoma/ partial
transection of the airway
NOTE;
If such conditions exist, it may be safer to support oxygenation and
ventilation using noninvasive means until a definitive airway can be
established/ to perform an immediate surgical airway.
20. CONTRAINDICATION CONT…
Relative contraindications include severe laryngeal or supra-laryngeal
edema as a consequence of ;
Bacterial infection
Burns
Anaphylaxis
Other difficulties may be related to anatomic features/
injuries/physiologic status of the patient / the skill set of the clinician.
22. Recommendations from the team
Consultation is mandatory (lets make use of the seniors frequently)
Intention of calling ICU /INTENSIVIST should be made by the doctor /SHO AND
FOLLOW UP.
REQUEST for VENTILATION &MONITORING TOOLS FOR AIRWAY MANAGEMENT.
AVOID SENDING UNSTABLE PATIENTS TO THE WARD BEFORE BEING STABILIZED
AT EMERGENCY.
WRITE YOUR NAMES AND SIGN DURING CLARKING THE PATIENT.
ALWAYS RECORD THE TIME AND DATE YOU HAVE SEEN THE PATIENT
RECORD ALL EVENTS & INFORMATION FROM PATIENTS AND ATTENDANTS
23. Recommendations…..
DOCUMMENTATIONS OF EACH &EVERY MESSAGE FROM ANY CONSULTATION
MADE.
PRIMARY DOCTOR SHOULD TAKE COMPREHENSIVE HISTORY &EXAMINATION.
SOP/TRIAGE AT EMERGENCY WITH PROPER HISTORY &EVALUATION BASED ON
A,B,C,D,E BASIS.
HOW TO DETERMINE A DETORIATING PATIENT???
ITS MANDATORY TO INFORM THE SURGEON ON CALL ABOUT EACH PATIENT
BEFORE IS TRANSFERRED OR AMITTED TO THE WARD,
ALWAYS DISCUSS AS ATEAM ON CALL FOR PROPER DIAGNOSIS AND PLAN FOR
THE PATIENT.
