Case Presentation

Dr.Md.Mahbub-ul-alam
 Particularis of the patient
• Name : Rahman
• AGE: 17 years
• Sex: Male
• Religion : Islam
• Occupation: Student
• Marital status: Unmarried
• Address: Bhanga , faridpur
• Date of admission: 18/7/2022
 Chief complaints
• Weakness of both upper and lower limbs for 4 days
• Severe respiratory distress for 6 hours
 History of present illness
According to the statement of the patient attendant, the patient
was reasonably well 14 days back before ICU admission. Then he
suffered from fever which was low grade, intermittent, no chills
and rigors, lasted for 3 days. Fever was associated with dry cough
and relieved in 4 days. No abdominal pain, vomiting, loose stool,
burning micturition, headache, confusion during this illness.
Two days later, he experienced tingling sensation over feet,
following which he developed weakness of both lower limbs.
 CONT....
Initially he noticed heaviness of both feet, then the legs and subsequently
weakness has been gradually progressive from inability to get up from
floor, difficulty in walking with twisting of ankle, and lastly unable to move
both the lower limbs within 2 days.

Within 1 day he also developed weakness of both upper limbs. Weakness

became progressive that there was difficulty in rolling over bed, raising
head and holding neck. Then he developed difficulty in breathing which
was rapidly worsened to severe respiratory distress associated with
inability to cough.
 Cont……
No history of blurring of vision, drooling of saliva, deviation of angle of
mouth, involuntary movement, fatigability and fluctuation of weakness,
reduced sensation or pain over body, skin rash, photosensitivity, any
recent trauma, consumption of preserved food items, any recent
vaccination.
Then he was brought to BSMMC emergency unit, then he was admitted
to BSMMC (medicine dept)and treated accordingly and he was transferred
to ICU (BSMMC) for better management.
Past medical or surgical history :
No history of similar complaints in the past any other medical disorder

Family history: There is no history of similar type of disorder.

Personal history: Bowel and bladder habit is also normal. He is nonsmoker.

Socioeconomic history: He comes from a lower class family

Occupational history: Student

 Cont……
Treatment history: he had takened over the counter medications for his
fever and cough 2 weeks back but details are not known.

History of allergy: No history of allergy .

Immunization history: He is vaccinated according to EPI schedule and also

covid vaccinated.

Travel history :Not significant

 • Apearance – Critically ill
• Body built- Average
• Nutritional status- Average
General • Decubitus- Supine
• Co-operation- Non- cooperative
examination
• Anaemia- AAbsent
• Jaundice- Absent
• Cyanosis- Absent
• Pulse- 110 beats/min
• Blood Pressure-100/70 mm of Hg
• Respiratory rate- 20 breaths/minute
• Temperature- 980F
[[[[[[[[[[[[[[[[[[[[[[[[
Systemic examination
 Neurological system
• Higher psychic function : Disoriented
• Signs of meningeal irritation: Absent
• Examination of cranial nerves :Could not be evaluated
• Fundoscopic Examination-Could not be evaluated.
• Motor functions :
• Bulk of the muscles-Equal in both upper and lower limb
• Tone of the muscle- Diminished in both upper and lower limbs
• Power of muscle-Could not be evaluated
• Reflexes – jerks are absent in both upper and lower limbs
• Sensory function- Could not be evaluated
• Cerebellar signs- Could not be evaluated
• Gait- Could not be evaluated
 Respiratory system
• Respiratory rate-20 breaths/min, irregular gasping breathing.
• Shape of the chest –Normal
• Chest expansion-Diminished
• Percussion-NAD
• Breath sound-Vesicular
• Vocal fremitus :Not evaluated
• Added sound - Crepitation (++)on both lung fields
 Cardiovascular system
• Pulse rate: 110 beats/min
• BP -100/70 mm of hg
• Precordium:
• No visible cardiac impulse
• No engorged vein
• Apex beat –Normal in position
• 1st and 2nd heart sound -Normal
• No murmur , pericardial rub
Other system examinations : NAD
 Salient features

Mr. rahman, 17 years old boy, normotensive, non diabetic, non-smoker hailing from
bhanga, faridpur, presented with history of fever and cough 2 weeks back, then
acute onset of symmetrical limbs weakness which is progressing from lower limbs to
upper limbs, trunk and ultimately respiratory muscles within 3 days. No feature of
sensory and autonomic involvement. No history of blurring of vision, drooling of
saliva, deviation of angle of mouth, involuntary movement, fatigability and
fluctuation of weakness, skin rash, photosensitivity, any recent trauma, consumption
of preserved food items, any recent vaccination.
PROVISIONAL DIAGNOSIS
?
Acute Inflammatory Demyelinating Polyneuropathy
( Guillain-barre syndrome) with type 2 respiratory failure
 Causes of ICU Referral
• Severe Respiratory distress needed assisted ventilatory support
• Unable to protect airway needed endotracheal intubation
 Journey at ICU
18/7/22 : Initial assessment and resuscitation:
Patient was unconscious and unable to obey
command, airway is not patent , there is pooling of
secretion in mouth, severe breathing difficulty was
present, respiratory rate was 20 b/min, irregular
gasping type breathing, used accessory muscle of
respiration, on auscultation bilaterally air entry was
equal but poor, spo2 88% on NRB mask with 15L O2.
On circulation BP was maintained at 100/70mmhg
with pulse 110b/min, regular, without inotrops.
GCS was E3,V2,M1 and no sign of C-spine instability.
 Plt 125000 Plt 15000
RENAL S.Cr 2.23mg/dl S. INVESTIGATION S.Cr 6.27mg/dl
S.Urea Cr4.52mg/dl S. Urea 253
103Mg/dl S.Urea mg/dl
170mg/dl

S.ELECTROLYES S.Na+144mmo S.Na+ S.Na

l/l 150mmol/l 145mmol/l
S.K+ S.K + S.K +
3.5mmol/l 5.53mmol/l 5.8mmol/l

COAGULATION PT/INR 30 PT 18.9 INR 1.21

PROFILE /2.65 INR 1.5 APTT 51sec
APTT 35.8sec APTT 42sec
D Dimer
>10Micro/l

OTHERS ABG: WBCT is more WBCT is more than WBCT is more

PH 7.2 than 20 mins 20 mins than 20 mins
PO2 51 mm hg
Pco2 30 mmhg
Hco3 14 mmol/L
Thank you
 ICU Admission
• A service for patients with potentially recoverable
conditions who can benefit from more detailed
observation and invasive treatment than cannot be
safely provided in general wards.
 ICU Triage
• admission criteria remain poorly defined
• identification of patients who can benefit from ICU care is
difficult
• demand for ICU services exceeds supply
• rationing of ICU beds is important
 Prioritization Model
Priority 1
critically ill, unstable
require intensive treatment and monitoring that cannot be provided
elsewhere
ventilator support
continuous vasoactive infusions
mechanical circulatory support
no limits placed on therapy
high likelihood of benefit
 Prioritization Model
• Priority 2
– Require intensive monitoring
– May potentially need immediate intervention
– No therapeutic limits
– Chronic co-morbid conditions with acute severe illness
 Prioritization Model
• Priority 3
– Critically ill
– Reduced likelihood of recovery
– Severe underlying disease
– Severe acute illness
– Limits to therapies may be set
• no intubation, no CPR
– Example : Metastatic malignancy complicated by
infection, or airway obstruction
 Prioritization Model
• Priority 4
– Generally not appropriate for ICU
– May admit on individual basis if unusual
circumstances
– Too well for ICU
• mild CHF, stable DKA, conscious drug overdose,
peripheral vascular surgery
– Too sick for ICU (terminal, irreversible)
• irreversible brain damage, irreversible multisystem
failure, metastatic cancer unresponsive to
chemotherapy
 Objectives Parameters Model

• Physical findings (acute onset)

– anuria
– airway obstruction
– coma
– continuous seizures
– cyanosis
 Objectives Parameters Model
• Vital signs
– HR < 40 or > 150
– SBP <80
– MAP <60
– DBP >120
– RR > 35

JCAHCO
 Objectives Parameters Model
• Laboratory values
– Sodium < 110 or > 170
– Potassium <2.0 or > 7.0
– PaO2 < 50
– pH < 7.1 or > 7.7
– Glucose > 800 mg/dL
– Calcium > 15 mg/dL
– toxic drug level with compromise
 ICU Admission Criteria
• Potential or established organ failure
• Factors to be considered
– Diagnosis
– Severity of illness
– Age and functional status
– Co-existing disease
– Physiological reserve
– Prognosis
– Availability of suitable treatment
– Response to treatment to date
– Recent cardiopulmonary arrest
– Anticipated quality of life
– The patient’s wishes
Thank you