A 48-year-old male farmer presented with pain and swelling in his right thigh for 10 days following a fall. Examination found restricted and painful right hip and knee movement. Investigations revealed anemia and elevated ESR. He was admitted for right femur fracture and developed respiratory distress. His condition deteriorated and he suffered cardiopulmonary arrest. Resuscitation attempts failed and he was declared dead from a suspected pulmonary thromboembolism complicating his injuries, diabetes and hypertension.

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