NON ACS MORTALITY

CASES
MARCH 2016 .

CASE 1
68 years old female
DOA 19th Feb 2016
DOD 3rd March 2016
Cause – Sepsis secondary to HAP

Refer to HPP for chest tube insertion of right sided pleural effusion on 19th Feb 2016 .Admitted to private hospital on 11th December 2015 for right sided pleural effusion Echo : severe TR secondary to dilated RA annulus : moderate MR secondary to dilated LA annulus : LVEF 45% Pleural fluid aspirate transudate Pick tail drainage inserted on 24th january 2016.

right large pleural effusion Refer to CTC for chest tube insertion and pleurodesis (done on 22nd Feb ) On 24th Feb. On 25th Feb. WCC 20. her vital signs was stable. she was transferred to CCU and IV antibiotics upgraded to Tazosin .5 . platlet 179. Lungs finding showed generalized rhonchi. She was intubated and started on IV ceftriazone. Hb 9. patient had respiratory distress with high grade fever.Upon admission patient was comfortable.

drained between 80-150cc daily. HD was initiated. serous ). Chest tube was still draining about 100cc. CTC reviewed the patient daily. CPR commenced but patient died. On 3rd Mac patient collapsed and develop PEA.26th Feb she was referred to nephro team for AKI. second HD was done. . Chest team was referred for management of persistent right pleural effusion (chest xray on 28th Feb showed persistent right pleural effusion with chest tube insitu. On 1st Mac. her chest tube was kept . Chest team continued the current management and KIV bronchoscopy if tracheal aspirate C+S negative.

CASE 2 71 years old female DOA 8th March 2016 DOD 22nd March 2016 Cause – Pneumonia .

Underlying DM. HPT and on thyroxine replacement Rx for post thyrodectomy H/O admission in Dec 2015 for decompensared CCF and has a NPS appointment Premorbid : bed bound for past 2 years ( after H/O fall) and bilateral eyes blindness .

IV lasix was initiated. She was also transfused 1 PC and plan to refer to OGDS . RP normal) Admitted to C8 with diagnosis of Decompensated CCF. No h/o fever. not tachypnea.6 plt 346.c/o progressive dyspnea 2 days and productive cough 2/52. Clinically. v/s BP 183/91.2 Hb 8. alert. wcc : 12. Lungs : bibasal crepitation. PR 75 and afebrile. pedal edema Ix : chest Xray ( cardiomegaly with congested lung fields and bilateral pleural effusion.

GCS dropped to 5/15. ABG : pH 7. IV antiobiotic was escalated to rocephine . HCO3 36. pCO2 7. She had a spiking temperature and lungs finding showed left lower zone crepitation. She was refered to gastro team for OGDS ( plan to scope once patient was stable as anemia likely secondary to IDA and there is no clinical evidence of active bleeding) .5.On 8th March ( at night of admission). Initiated on IV unasyn with clinical impression of community acquired pneumonia  On 9th March .4. pO2 15 ).5. No focal neurological deficit.

ECG then showed inferior and lateral T inversion.On 10th march. Bedside echo showed LVEF of 60%. then to IV meropenam ( 16th march) in view persistant high spiking temperature. transferred to CCU as her BP dropped . on 18th march . patient had respiratory distressed and she was then intubated. She was also refered to nephro team for worsening renal profile but didn’t required HD. LA/LV not dilated and LV wall thickness preserved. . CT brain revealed no ICB IV antibiotic was changed to Tazocin ( 12th march) .

CPR and IV adrenaline given but pronounced death after 20 min resuscitation. multiple blood C+S NG. .2 to 9. patient was extubated.6). at night patient was noted unresponsive . completed iv meropenam ( Day 7. WCC dropped ( from 15. on day of admission ) showed E. by ID team) and tranfered to C8. ECG revealed PEA. urine C+S (8th March. However . Coli On 22th march.Patient had much clinical improvement in ccu Repeated Chest Xray improved.

CASE 3 72 years old male DOA 21st March 2016 DOD 22nd March 2016 Cause – urosepsis .

HPT. upon reinsertion noted frank hematuria and refer to casualty Also c/o mild left sided chest pain at 2pm with SOB at rest.Underlying DM . But the urinary catheter was reinserted that evening as patient cant PU. . patient went to k/k where his CBD was off. BPH (CBD since Jan 2016) CAD with stented once in 2000 Earlier in the morning.

3 Imp: Acute inferior MI Killip 2 Urosepsis secondary to long standing CBD with traumatic urinary catheter insertion .O/E confused.5) Lungs : bibasal crepitation. v/s ( BP :130/99. Tem : 40. SpO2: 100% on NPO2 CBD frank hematuria. plt 151. Hb 13. PR : 126. AST 151. LDH 261 WBC : 47. ECG (7pm) : ST elevation inferior leads ( no posterior wall and right ventricle involvement) CK 108.

KIV COROS once no bleeding Bedside echo: LVEF 30-35%. LV thickness still preserved . global hypokinesia with more pronounced at inferoseptal wall. IV unasyn started.Admitted to CCU. was given s/c fondaparinux only and not for antiplatlet in view of frank hematuria.

On 22nd march night. patient’s blood pressure dropped . LMWH off. Patient was referred to nephro team for HD support as developed severe metabolic asidosis with AKI. refer to urology team where bladder irrigation was started and IV antiobiotic was continued. Developed PEA . . As frank hematuria persist.On 22nd march early morning. CPR and IV adrenaline commenced but resuscitation was unsuccessful. Fluid resuscitation initiated and later commenced on inotrope support. SLED was initiated but terminated as blood pressure dropped and patient became unconscious.

CASE 4 83 years old female DOA 5th march 2016 DOD 6th March 2016 Cause – Aspiration pneumonia .

Underlying DM. ECHO : LVEF 30 -35%. severe hypokinesia and severe MR c/o SOB and unwell for 2 days h/o choking during feeding no fever . COROS was refused . premorbid status: partially ADL dependant and dementia H/O CAD ( admitted for NSTEMI in 11/2015 and APO secondary to ACS in jan 2016).

1 CK 1741.4 SpO2 : 90% HFM. LDH 1294.9/262 ABG: pH 7. AST 746 ECG: LBBB Serum lactate 18 ( 0. pO2 4.Hb 10.3 RP: 152/5.36. PR 61.2 UFEME: leucocyte 2+.96. vital signs: bp 79/44. reflo : 10.O/E tachypnea. HCO3 6. no pitting edema Chest Xray : bilateral lower zone lungs hazziness Wcc 8.088.pCO2 3. Tem 35. nitrate neg .2 plt 262 CRP 15.5-1. lungs : bilateral crepitation .6).6.3/106/13.

DIL/DNR issued On 6th march night. patient noted unconscious. ECG revealed asystole. . cover for ACS started on IV rocephine. severe metabolic acidosis secondary to aspiration pneumonia/ urosepsis 2. inotrope support and fluid ( 2 pints NS).Imp: 1.

CASE 5 60 years old male DOA 27th march 2016 DOD 27th March 2016 Cause – Acute stroke .

Electively admitted for COROS Indication: h/o inferior STEMI (from Hospital Kepala Batas in august 2015) Echo : LVEF 45% . hypokinetic segment at mid inferior posterior wall. LA and LV chambers dilated .

Walking with stable condition (according to nursing note) Noted patient less responsive. patient developed PEA. . lungs clear. PR 86. Vital sign: BP 160/90. resuscitation was done for 30 minutes but unable to revive patient.1. afebrile clinically not in respiratory distressed. ECG: old inferior MI blood test : FBC/ RP/ LFT normal range urgent CT Brain ordered However. reflo : 6.

CASE 6 84 years old male DOA 14th Feb 2016 DOD 18th March 2016 Cause – Urosepsis .

ABG : Normal range Treated with IV lasix . CKD. IHD ( 3VD and refused CABG). BPD on suprapubic catheterization and COPD H/O admission for decompensated CCF in 0ctober 2015 c/o progressive dyspnea for 2 days Associated orthopnea and pedal edema No fever/urti 0/e hemodynamically stable and afebrile. lungs bibasal crepitation ECG: SR. Chest Xray : congested lung field.Underlying DM on insulin Rx .

PR 100. nitrate +ve .30pm noted acute altered mental status and persistant vomiting V/sign: BP 130/70. UFEME leucocyte 2+. Tem: 39 ECG :SR with no acute dynamic changes Lungs bibasal crepitation and clinically not tachypnea Electively intubated in view of unable to protect airway and drop of GCS Urgent CT Brain : no ICB Wcc : 13. However.6 Hb 11.2 plt 354. at 5. clinically improved and treatment was commenced.On 15th march morning.

. However. patient still having high spiking temperature and became hypotensive.On 17th march. on 18th march early morning. refer to urology team for suprapubic catheter change and urgent ultrasound KUB was ordered. IV antibiotic was upgraded to Tazosin. inotrope support was initiated . patient was expired.