This document summarizes a death audit report for a 67-year-old male patient who passed away after being admitted for 3 days. The patient initially presented unconscious after suffering a stroke. He developed complications including heart arrhythmias, kidney injury, and deteriorating neurological function. Despite attempts at resuscitation, the patient went into asystole and could not be revived. The causes of death were determined to be a cerebrovascular accident exacerbated by underlying conditions of hypertension, coronary artery disease, and kidney injury.

1. DEATH AUDIT
DECEMBER 2016
Dr. Sujay Iyer
I Year PG
General Medicine Unit IV

2. PATIENT DETAILS
 Name: Mr. Ranganathan
 Age/ Gender: 67 years/ Male
 MR number: 16/402110
 IP number: 16/061538
 DOA: 15/12/2016 at 18:54
 DOD: 19/12/2016 at 01:30
 Duration of Stay: 3 days

3. PRESENTING COMPLAINT
 Patient was brought to the ER on 15/12/16 at 5 pm
in an unconscious state with ET tube in-situ without
any ambu-bag or ventilatory support.

4. HISTORY OF PRESENTING ILLNESS
 Patient had sudden onset of loss of consciousness after
he complained of dizziness on 10/12/16 which resulted
in a slip and fall.
 H/O involuntary micturition (+)
 H/O deviation of angle of mouth to right side (+)
 H/O weakness of left upper and lower limb.
 He was taken to Manakulla Vinayagar Hospital where he
was diagnosed as right MCA territory infarct with
hemorrhagic transformation after a CT scan brain was
done (Large left fronto-parietao-temporal infarct with
hemorrhagic transformation and significant midline shift)
 He was intubated and ventilated due to poor GCS.

5. HOPI
 Patient was treated with Mannitol, Atorvastatin,
Ceftriaxone and Dexamthasone.
 Outside investigations on 13/12/16:
 Urea: 133; Creat: 4.43
 TC: 18,900
 2D ECHO: Inferior wall hypokinesia (+), LVH (+), LVEF
– 45%, CAD (+).
 Decompressive craniotomy was advised, but since
patient’s attenders were unwilling; patient was
discharged against medical advice.

6. HOPI
 Patient was taken to PIMS and East Coast Hospital
where the same advice was given, but since
patient’s relatives were unwilling; he was
discharged against medical advice and taken
home.
 He was kept at home for a day with ET tube in-situ.
 On the afternoon of 15/12/16, patient started
gasping and was brought to MGMCRI for further
management

7. PAST HISTORY
 K/C/O Systemic Hypertension and Type 2 Diabetes
Mellitus since 4 years. On irregular medication
 Not a K/C/O PTB, Seizure disorder, Bronchial
Asthma.

8. GENERAL EXAMINATION
 HR – 120/min
 BP – 80 systolic
 RR – 24/min
 SpO2 – 98% on room air with ET tube insitu
 Temp – 103*F
 GCS – 3T/15
 CBG – 158 mg%
 Patient was immediately mechanically ventilated by
Critical Care team in Volume Control mode after
airway suction was done.

9. SYSTEMIC EXAMINATION
 R/S: NVBS (+). BAE (+). B/l conducted sounds (+)
 CVS: S1S2 (+). No murmurs.
 P/A: Soft, non-tender, no organomegaly.
 CNS:
 GCS - 3T/15. Unresponsive to painful stimuli.
 Left and Right UL and LL tone – Reduced.
 Bilateral plantars – Mute.
 Left pupil – Sluggishly reacting to light.

10. INITIAL MANAGEMENT
 Patient was immediately started on Inj. Dopamine
at 5mcg/kg/min.
 Neurosurgery, Critical Care and Ophthalmology
opinions were sought.
 Neurosurgery consult was for nil intervention.
 Poor prognosis was explained to the patient’s
relatives.
 Patient was admitted under GM IV in the ICU.

11. ECG

12. CHEST X-RAY

13. INITIAL INVESTIGATIONS
PATHOLOGY BIOCHEMISTRY BIOCHEMISTRY
CBC:
Hb – 14.9
TC – 13,900 (N: 80%)
Plt – 96,000
URINE ROUTINE:
Pus cells – (+)
Bacteria – Occasional
Sugar – (+)
ABG:
pH – 7.45
pCO2 – 37
pO2 – 33
HCO3 - 25
RFT:
Urea – 32.9
Creat – 6.7
ELECTROLYTES:
Na – 143
K – 4.6
Cl – 107
Ca – 8
Ph – 4.8
Mg – 1.5
LFT:
T.P – 6.4
Alb – 3.8
T.B – 2.3
D.B – 0.9
AST – 84
ALT – 49
AlkP - 75
Amylase – 75
GGT – 71
PT – 16 (13.5)
INR – 1.2
PTT – 26 (32)
CARDIAC MARKERS:
TROP I – (-)
CPK T – 737
CPK MB – 15

14. INITIAL TREATMENT
 Inj. Piperacillin + Tazobactum 4.5g IV stat then 2.25
g IV TDS.
 Inj. 3% NS IVF at 20 ml/hr.
 Inj. Pantoprazole 40 mg IV OD.
 Inj. Noradrenaline IVF at 1.3 ml/hr (Targer MAP of
65 mmHg)
 Syp. Lactulose 30 ml TDS.
 Inj. Dopamine was tapered off.

15. 15/12/16
 At 10 pm, patient was found to have a HR> 200/min
on the monitor.
 ECG revealed SVT. Pulse was not felt.
 Patient was cardioverted twice with 50 J and then
once with 100 J.
 Patient reverted back to sinus rhythm.
 CVP line in subclavian vein was placed. Arterial line
was also placed.

16. 16/12/16
 Patient was on PCV mode with Inj. Noradrenaline.
 HR – 109/min. BP – 100/70. I/O – 2070/360.
 Unresponsive to deep painful stimuli.
 Nephrology opinion was sought in view of
requirement of hemodialysis for poor urine output.
 Dr. Hemachander advised hemodialysis under high
risk, patient’s relatives refused.

17. 17/12/16
 Patient was on CPAP mode. Noradrenaline had
been tapered.
 HR – 85/min. BP – 130/70 mmHg. I/O – 4133/2175.
 Patient was started on Inj. Amiodarone IVF at
2.2ml/hr in view of frequent SVT.
 Patient’s hyperkalemia was corrected.
 Neurologically, patient continued to be in status
quo.
 Hyoptonia in all 4 limbs
 Right plantar – extensor.
 B/L pupils – sluggishly reactive.

18. INVESTIGATIONS
17/12/16 18/12/16
Urea – 99
Creat – 6.5
Na – 149
K – 5.0
Cl - 117
Urea – 146
Creat – 5.17
Na – 149
K – 4.9
K - 117

19. 18/12/16
 Patient was on PCV mode. On Inj. Amiodarone
infusion.
 HR – 89/min. BP – 220/90 mmHg. I/O – 4428/2365.
 Patient was unresponsive to deep painful stimuli.
 Neurologically deteriorating as pupils were found to
be dilated and fixed, not reactive to light.

20. 18/12/16
 At 11 40 pm, patient was found to have HR >
200/min. Monitor showed Ventricular Tachycardia.
 BP – 70/40 mmHg. SpO2 – 62% at 100% FiO2 at
PCV mode.
 Patient was given 2 cycles of defibrillation at 150 J.
 CPR was initiated according to ACLS protocol.
 Patient continued to have VT despite 5 cycles of
defibrillation and Inj. Adrenaline.
 At 12 30 am, Inj. Amiodarone 150mg bolus was
given.

21. 19/12/16
 At 12 45 am, patient developed SVT. Inj. Adenosine
was administered.
 At 1 am, patient went into bradycardia. CPR was
continued.
 At 1 25 am, patient went into asystole. Heart
sounds were absent.
 Despite all resucitative efforts, patient was declared
dead at 1 30 am.

22. CAUSE OF DEATH
 Cerebrovascular Accident – Left middle cerebral
artery infarct with hemorrhagic transformation.
 Systemic Hypertension.
 Coronary Artery Disease.
 Acute Kidney Injury.
 Acute on Chronic Kidney Disease.

23. THANK YOU