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70M ALTERED SENSORIUM ET TUBE INSITU

 


70 year male was bought to Casuality in an intubated state


HOPI:

Pt is apparently asymptomatic until  2 days ago then he developed sudden onset of abdominal discomfort  and SOB after dinner. Patient was taken to nearby hospital in altered sensorium and was found Grbs-30 mg/dl . patient was intubated i/v/o poor GCS-5/15 and was bought to our hospital for further management with ET tube in situ

PAST HISTORY:

H/O Right inguinal surgery on 15/09/23

K/c/o hypertension since 12 yrs( on unknown medication)

K/c/o Pulmonary Tuberculosis 30 years back( used ATT for 6 months)


PERSONAL HISTORY:

DIET :mixed

APPETITE : Normal

SLEEP: adequate 

BOWEL AND BLADDER :Regular 

Addictions : Patient was an Alcoholic and smoker 30 years ; stopped after diagnosed with Tuberculosis.


FAMILY HISTORY: 

N/K/C/O DM, Hypertension,Epilepsy, Asthma, Thyroid disorders.


GENERAL EXAMINATION:

Patient is on Mechanical ventilation.

Dilated neck veins present.

No Pallor,Icterus,clubbing,cynosis.


VITALS:

TEMP: 97.2 F

BP: 160/90 MM/HG

PR: 98 BPM

GRBS: 91mg/dl



SYSTEMIC EXAMINATION:

RS:

Position of trachea :deviated to right,

Movement of chest decreased on right side.

B/L rhonchi at IAA,ISA.

B/L Crepts at MA,AA,IAA,ISA.


CVS : S1 , S2 heard, no precordial bulge, apical impulse at left 6th ICS 1cm medial to MCL.


P/A :distended abdomen,no organomegaly,bowel sounds -sluggish 


CNS: GCS :E1VtM1

Tone - normal in all four limbs

Reflexes- absent

Plantars- mute




PROVISIONAL DIAGNOSIS

ALTERED SENSORIUM SECONDARY TO ?HYPOGLYCAEMIA 

?ASPIRATIONAL PNEUMONIA 

POST INTUBATION STATUS

S/P RIGHT HERNIOPLASTY


INVESTIGATIONS 

CHEST X-RAY 

24-09-2023


26-09-2023


















Hemogram

25/9/23

26/9/23

Hb 

9.4

10

TLC

18400

19500

PCV

31.8

35.2

MCV

83.2

85

MCH

24.6

24.2

MCHC

29.6

28.4

RDW-CV

17.7

17.6

RBC COUNT

3.82

4.14

PLATELET 

1.89

1.57

SMEAR

NC-HC 

NC-HC

N/L/E/M/B

84/05/01/10/00

83/02/00/15/00



LFT

24/9/23

26/9/23

27/9/23

TB

0.47

0.82

0.80

DB

0.16

0.15

0.19

AST

13

15

220

ALT

18

8

83

ALP

100

123

129

TP

6.1

6.2

5.2

ALB

3.3

3.1

2.01

A/G

1.18

1.03

0.63




RFT

24/9/23

26/9/23

UREA

20

31

CREATININE

0.8

0.8

URIC ACID

2.4

2.9

CALCIUM

9.3

9.9

PHOSPHOROUS

4.1

3.1

SODIUM

137

137

POTASSIUM 

4.3

4.4

CHLORIDE

102

103




ABG

24/9/23

25/9/23

26/9/23

5:59AM

11PM

pH

7.19

7.17

7.23

6.71

pCO2

80.1

63.2

70.8

220

pO2

130

80.5

101

82

HCO3

29.4

22.4

28.7

26.7

St.HCO3

24.2

19.8

24.8

12.5

BEB

-0.3

-5.5

0.4

-15.4

BEECF

1.9

-4.9

1.8

-9.2

TCO2

63.2

50.5

61.8

70.6

O2 Sat

97.2

95.6

97.1

83.2

O2 count

15.9

10.1

14.1

12.2





25/9/23

BT

2.30sec

CT

5sec

APTT

34sec

PT

17sec

INR

1.25sec




24/9/23

Anti-HCV

Non reactive

HBSAG

Negative

HIV

Non reactive

Blood Group

A+ve

Blood Lactate

9

RBS

90




26/9/23

Serum lipase

22

Serum amylase

40.8

LDH

225




27/9/23

Pleural sugar

79

Pleural protein

2.2

Pleural amylase

10

Pleural LDH

210


24-09-2023

Pulmonology referal was taken in view of chest X-ray changes



25-09-2023
Pulmonology Review 

TREATMENT 

1) RT FEEDS - 100ml water 2nd hourly, 200ml milk+ protein powder 4th hourly

2) IV FLUID NS @50ml/hr

3) INJ MIDAZOLAM + FENTANYL @4ml/hr increase/decrease accordingly

4) INJ PIPTAZ 4.5gm IV/BD

5) INJ CLINDAMYCIN 600mg IV/TID

6) INJ PAN 40 mg IV/OD

7)  INJ ZOFER 4mg IV/TID

8) NEBULISATION WITH DUOLIN 8th HOURLY

9) NEBULISATION WITH MUCOMIST 12th HOURLY

10) NEBULISATION WITH IPRAVENT 4th HOURLY

11)ET TUBE SUCTIONING 2nd HOURLY

12)POSISTION CHANGE 2nd HOURLY



26-09-2023
General surgery referal was taken in view of bowel sounds not heard




TREATMENT 

1) RT FEEDS - 100ml water 2nd hourly, 200ml milk+ protein powder 4th hourly

2) IV FLUID NS @50ml/hr

3) INJ MIDAZOLAM + FENTANYL @4ml/hr increase/decrease accordingly

4) INJ VANCOMYCIN 1gm IV/BD

5) INJ CEFTAZIDIME 2gm IV/TID

6) INJ CLINDAMYCIN 600mg IV/TID

7) INJ PAN 40 mg IV/OD

8)  INJ ZOFER 4mg IV/TID

9) NEBULISATION WITH DUOLIN 8th HOURLY

10) NEBULISATION WITH MUCOMIST 12th HOURLY

11) NEBULISATION WITH IPRAVENT 4th HOURLY

12)ET TUBE SUCTIONING 2nd HOURLY

13)POSISTION CHANGE 2nd HOURLY

14) TAB ISONIAZID 5mg/kg 350mg

TAB RIFAMPICIN 10mg/kg 700mg

TAB PYRIZINAMIDE 25mg/kg 1750

TAB ETHAMBUTOL 15mg/kg 1050

DIAGNOSIS 

POST INTUBATION STATUS SECONDARY TO ASPIRATION PNEUMONIA WITH ALTERED SENSORIUM SECONDARY TO HYPOGLYCEMIA(GCS 5/15) WITH RIGHT LUNG BRONCHECTIASIS WITH RIGHT LUNG FIBROSIS SECONDARY TO POST TUBERCULAR SEQUELAE(30 YEARS AGO) WITH S/P HERNIOPLASTY(RIGHT INGUINAL)POD-10 WITH K/CIO

HT SINCE 12 YEARS

DEATH SUMMARY

70 YEAR MALE WHO WAS A K/C/O PULMONARY TB WITH POST TB FIBROSIS OF RIGHT LUNG AND HT SINCE 12 YEARS WITH A HISTORY RIGHT INGUINAL HERNIOPLASTY POD-8 WAS BROUGHT TO ER(24/9/23 5:20PM) WITH ET TUBE INSITU ON MECHANICAL VENTILATION ACMV-VC MODE UPON ADMISSION ABG SHOWED TYPE 2 RESP FAILURE, RESP ACIDOSIS.

NECESSARY INVESTIGATIONS WERE DONE AND PATIENT WAS SHIFTED TO ICU.

PULMONARY REFERRAL WAS TAKEN AND ADVISE FOLLOWED. HRCT SHOWED CONSOLIDATION IN MULTIPLE SEGMENT IN LEFT LUNG LOWER LOBE-ACUTE INFECTION.

BRONCHECTIASIS IN ANTERIOR SEGMENT OF LEFT LUNG UPPER LOBE AND SEQUELEA OF CHRONIC INFECTION. PULMONOLOGY REVIEW REFERRAL WAS TAKEN AND ADVISE FOLLOWED.

SURGERY REFFERAL WAS TAKEN I//O NO BOWEL SOUNDS AND ADVISE FOLLOWED.

SERIAL ABGS SHOWED PROGRESION OF RESPIRATORY ACIDOSIS. IN/O INCREAING PCO2 GRADUAL FALL IN SATURATION PATIENT HAS BEEN SHIFTED TO ACMV-VC MODE TO ACMV-PC MODE. DESPITE ALL THE EFFORTS PATIENT HAD FALL IN SATURATIONS AND BP. PATIENT WAS STARTED ON IONOTROPES IN/O FALL IN SATURATION; ABSENT CENTRAL AND PERIPHERAL PULSES PATIENT WAS INITIATED ON CPR.PATIENT COUNT BE REVIVED AND DECLARED DEATH ON 26/9/23 11:21PM




LEVEL 1
Remembering 


Recalling the patient history and sequence of events leading him to be in an intubated state


LEVEL 2
Understanding 

Understanding the concepts of repsiratory failure 


How common is aspiration pneumonia
https://www.ncbi.nlm.nih.gov/books/NBK470459/

A case-control study showed that the incidence of aspiration pneumonia was 18% in nursing home patients and 15% in community-acquired aspiration pneumonia. Since most cases of aspiration pneumonia are silent or unwitnessed, the true incidence rate is difficult to ascertain.

What organisms can be seen in aspirational pneumonia and how to differentiate it from pneumonia 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5564131/


A prospective study that used the bronchoalveolar lavage level of pepsin as a surrogate marker of aspiration in ICU patients has reported that 88.9% of the patients had at least one aspiration event [20]. Unwitnessed gastric aspiration is thought to be important to explain many cases of perioperative pulmonary dysfunction. However, most aspiration pneumonitis cases are often misdiagnosed as bacterial pneumonia, whereby the patients are consequently given the inappropriate treatment

LEVEL 3



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