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2

nd
April 2014
Dr. Megha Unadkat
8/13/2014 1
PATIENT IDENTIFICATION
Name- Baby of D.N
Sex- Female
Date of Admission 02/03/14 at 10.00 pm
Date of demise- 03/03/2014 at 10.55 am
Duration of stay ~ 13 hrs


8/13/2014 2
CHIEF COMPLAINT & HPI
Fever 3/7
Sudden onset
Low-high grade fevers associated with mild cough
Hx of poor feeding and loss of appetite
No hx of wheezing/DIB
No hx of vomiting/diarrhea
No hx of convulsions
No hx of ear/nasal discharge
No hx of difficulty in micturition

Taken to a local hospital where baby was given injection
Diclofenac and Diazepam PR
8/13/2014 3
BIRTH HISTORY
Patient delivered via emergency C/S on the 21/3/2013 at AKH
due to severe IUGR and breech presentation with cord around
the neck at GA of 36 weeks.
Birth Weight = 1.6 Kg
Baby had Apgar score of 7- 8
Given IVF stayed for 3 days
Exclusively breastfed for 4/12
Maternal factors
Reduced fetal movements
PIH noted in last 2 ANC visits Total 6 visits



8/13/2014 4
ON EXAMINATION
AVPU , afebrile (37C), pale +, not jaundiced ,
cold extremities
RR- 77-83 b/min (tachpynoea)
HR- 189 bpm (tachycardia)
SPo2 83% on RA , 95% on 5L of O2
(babymask)
Weight - 5.5 Kgs
Dehydration: moderate


8/13/2014 5
SYSTEMIC EXAMINATION
RS
LCWI, Intercostal recessions
No area of tenderness
Bilaterally symmetrical expansion
Bilateral coarse crackles, Right >>Left side

CVS

Regular, strong peripheral pulses.
Apex beat at 4th ICS
S1 and S2- normal, no murmurs


8/13/2014 6
P/A
Normal contour, soft, non tender
Liver 2 cm enlarged below RSCM
Kidney and spleen not palpable
Tympanic percussion and normal bowel
sounds heard.


8/13/2014 7
PROVISIONAL DIAGNOSIS
Severe Pneumonia with septic shock
8/13/2014 8
INITIAL LABS
CBC





Malaria (dual) negative





8/13/2014 9
WBC 7.1 K/uL
HB 8.6 g/dl
Platelets 85 K/uL (thrombocytopenia)
Electrolytes






Creatinine: 69.63 umol/L (59-104)

8/13/2014 10
Sodium 128.12 mmol/L 136-145
Potassium 5.26 mmol/L 3.3-5.5
Chloride 103.45 mmol/L 98-104
HCO3- 7.24 mmol/L 18-28
Anion Gap 17.43 mmol/L 6-20
CXR
8/13/2014 11
MANAGEMENT (02:30 HRS - CASUALTY)

Plan:
NS bolus 110 mls IO
DNS maintenance IO
IM ceftriaxone 500mg STAT/OD (75mg/kg)
Salbutamol Nebs 2.5 mg Q3H
Oxygen 2L/min



8/13/2014 12
IN THE WARD 09:30 AM
o/e: Still drowsy, dyspneic, pale, cold extremities,
faint peripheral pulses, capillary refill > 3 seconds ,
on O2 via nasal prongs, acidotic breathing, no
peripheral line present
RS: crackles R>>L
CVS: tachycardic
P/A: soft, liver enlarged 6-7cm BRSCM

8/13/2014 13
Impression
Severe Pneumonia (?Aspiration) with
acidosis
Anemia in heart failure
Septic shock

8/13/2014 14
Plan:
To cannulate (successful)
To do blood grouping/cross matching
Transfuse whole blood 120mls Lasix 6mg before
transfusion
NS bolus 120 mls (given twice)
IV clindamycin 60mg STAT/Q6
Discuss with ICU for transfer ( no space in ICU
until a transfer out)
Mother was informed

8/13/2014 15
IN THE WARD 10:55 AM

Baby went into Cardiopulmonary arrest
Bag & Mask ventilation with chest compressions
were initiated
IV adrenaline was started
Consultant + ICU team informed
Intubation was done with ETT and suctioning
done

8/13/2014 16
20 cycles of adrenaline given with no response
(HR still <60)
Portable ultrasound was brought to rule out
pericardial effusion/tamponade
Revealed no effusion but no pumping
movement of the heart
CPR stopped > 2 hrs
Family informed
8/13/2014 17
CAUSE OF DEATH ???

Severe Pneumonia with acidosis leading to
Respiratory failure
Septicemia
Anemia in heart failure



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