PATIENT AGE GENDER CATEGOR COMORBI IP/OP CONDITI

Y DITIES ON AT CAUSE
PRESENTA OF DEATH
TION

A 20 yrs M NT - ED Unconsci Aspiration

ous due to
E1 V1 M1 drowning
B 62 yrs M NT COPD ED Gasping Myocardi
E4V1M1 al
infraction
C 74 yrs F NT DM ED Unconsci Myocardi
HTN ous al
E1V1M1 Infraction
D 46 yrs F NT BPAD ED Gasping Acute
HTN E4V1M4 Coronary
syndrome
E 41 yrs M T - HDU Conscious Respirato
,oriented ry failure

F 46 yrs M NT ICU Conscious Sepsis

,oriented with
Hypotensi MODS
ve
• Death occured between 1/1 / 2024 to 29/ 2 /2024
• In total 6 deaths
• ED deaths: IP deaths - 4:2
• Tribal : Non Tribal – 1:5
• Comorbidities :No knownComorbidities – 3:3
• Male : Female – 4:2
• Young adolescent- 1
Middle age - 3
Elderly – 2
CASE 1
• IDENTIFYING DATA

• NAME : F
• AGE : 46 years
• GENDER : Male
• D.O.A :20/1/2024
• D.O.M :21/1/2024
20/1/24
7:06 am
A 46 year old male came to ED with
c/o difficulty breathing ×7days
. C/o vomiting non billious, non blood stained.

Pt was a newly detected case of RVD and Milliary TB × 6 weeks

ago and started on ART and ATT 10 Days ago
Was admitted in Davanagere District hospital and discharged against
medical advise to seek treatment in our hospital.
• ON ARRIVAL

Conscious,Oriented

Vitals BP – 70/40 mmhg

PR- 110 bpm
SPO2- 75% RA  98% 15 lit O2

S/E RS – B/L Rhonci +

B/L Crepts +
Inv – CD 4 - 18
Management - INJ . HYDROCORT
PROVISIONAL DIAGNOSIS – RVD/ Milliary TB, CAP/ PCP/ Adrenal TB in shock

Admitted to HDU
1. Inj zostum
2. Inj Linezolid
3. Inj Septran DS
4. T.Pyridoxine
5. T. Fluconazole
6. IVF 75 ml /hr
 9:40 am
Conscious, Oriented
BP – 110/ 70 mmHg
SPO2 – 99% 10 lit O2 NRBM

INV:
Anemia
Hyponatremia
Hyperkalemia
Deranged LFT
21/ 1/24 BP- 100/60
9:30 Am RR – 22Cpm
Spo2 – 98% RA
Difficulty Breathing
11:30 Am Neb Duolin 6th hrly
SPO2 – 98@ 10 Lit O2

BP- 70/40 mmHg Inj Atropine

12 :00 Pm PR – 48 Inj Adrenaline
SPO2 – 72% 10 Lit O2 Inj Hydrocort
 Respiratory Acidosis

1:00 Pm
NAHCO3 6 amp over 4 hrs IV
 Gasping Inj Atropine
BP – 100/40
Inj NaHco3 3 amp
PR- 36
7pm Inj Noradrenaline 4 amp

Inj NaHco3 3 amp

8pm

8:50 pm Pt unresponsive
Bp – unrecordable Code blue announced
CPR started

9:20pm ECG – flat Declared Dead

vitals unrecordable
B/L Pupil dilated
Post death counselling
 HUMAN FACTOR
• Consideration of early intubation
• Antibiotics

SYSTEM FACTOR ANALYSIS OF PATIENT FACTORS

• Gap in documentation MORTALITY • Neglect
• Non availability of • Late seeking of health care
Intensivist • Denial to be referred to higher
center.
CASE 2

IDENTIFYING DATA :
NAME : D
AGE : 46 Yrs
GENDER : Female
D.O.A :
D.O.M :
 A 46 year old female came to the emergency department with sudden onset of
Breathing difficulty.

• HOPI
3 days ago pt came to the OPD with c/o pain over left lower limb and was unable to bear
weight on left leg. Pt was managed symptomatically in OPD basis. In the interim her symptoms
persisted.
On de day of consultation pt had sudden onset difficulty breathing hence brought to ED at 5:00 PM.

K/C/O BPAD on T. Risperidone 2mg 0-0-1

T. THP 2mg 1-1-0
K/C/O HTN on T. Amlong 5mg ½ - 0-0

Underwent CRIF- PFN for left sided intertrochanteric fracture × 4 months ago , was hospitalized for
a period of 3 ½ months and was discharged on
CONDITION ON ARRIVAL

IVF 2 Lit bolus

E4V1M4
Inj Atropine 2amp
5:00 PM GASPING Inj Adrenaline 1mg IV stat
BP – 60/50 Inj Dopamine 2 amp } 64 drops / min
Inj Dobutamine 7 amp }
PR – 50 Inj Noradrenaline 60 ml / min infusion
SPO2 - 80% RA

BP – 116/82
5:40 PM PR - 73
SpO2 – 88% 14 lit O2
 Pt unresponsive
6:15 pm
Pulse not palpable
BP – Not palpable
PR – Not palpable
SPO2 – Not paplable

ECG – Flat
6:30 Pm Pt declared dead
3 days ago, pt presented with c/o left lower leg pain
o/e – tenderness and pitting edema
Suspected to have DVT.
.
 HUMAN FACTORS
• Non availability of required investigation.
• Consideration of anticoagulant
• Consideration of intubation - gasping

PATIENT FACTOR SYSTEM FACTORS

• Poor psychological state • No proper guidelines for
• No support system usage of of ionotropes
followed.
ANALYSIS OF
MORTALITY