A VISHAL
1701006001
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Our. 70Yr old female patient came to the opd with chief complaints of
1)Blisters & swellings in the right lower limb Since 10 days
2)SOB since today evening.
HOPI:-
Patient was Apparently asymptomatic then she developed swellings of right lower limb which insidious in onset & gradually progressive associated with redness and then she developed pain which is insidious in onset &. Were increased & spreading till the thigh & later at home patient pricked the blisters with pin ,followed by which she developed increase in the pain for which she was taken to hospital & kept them on conservative management with antibiotics & daily dressing. At that time patient was unconscious, coherent, obeying commands and on day 4 of admission due to increasing pain And non healing blister debridement & fasciotomy was done following Which patient got anxiety attack on looking at the wound . According to Attenders there is sudden onset SOB & BP surge following which 2 d echo was done & showed EF of 60% on 3/9/22 & repeat ECHO on 6/9/22 ,showed RWMA in LAD territory & patient landed in altered sensorium since then & they left on LAMA to home followed by which she developed SOB at house & bought to hospital.
PAST HISTORY:-
Not a known case of DM/HTN
EXAMINATION:-
Patient was conscious, coherent,cooperative .
No pallor,Icterus,cyanosis , lymphadenopathy.
Temp- 93.4 f
PR -118 BPM
RR- 24 cpm
Bp- 130/90 mmHg
Cvs - S1 ,S2 +
CNS- NAD
R/S - BAE+
P/A - soft ,nontender
Provisional diagnosis:-
Necrotising fascitis ,S/P debridement & fasciotomy, sepsis with septic encephalopathy ,sepsis induced cardiomyopathy & respiratory failure.
INVESTIGATIONS:-
TREATMENT:-
INJ.MEROPEN 1 gm /IV/BD
INJ.CLINDAMYCIN 60 mg /IV/TID.
INJ.PAN 40 mg /Iv /OD
NEB DUOLIN & BUDECORT 6 th hrly.
TAB.DOLO 650 mg /RT/SOS
INJ.NEOMOL 1 gm /IV/SOS.
10/09/2022:-
1) INJ.MEROPENEM 1 gm/IV/BD 2)INJ.CLINDAMYCINb600 mg/IV/STAT
3)INJ.LASIX 20 mg IV BD.
4)INJ.PANTOP 40 mg IV /OD.
5).TAB.DOLO 650 mg RT sos
6)NEB .IPRAVENT, BUDECORT- INH 6 th hrly
7)INJ.NEOMOL 1gm IV SOS.
8) INJ.ATRACURIUM 2 amp+ 46 ml NS.
9)INJ.MIDAZ @5 ml/hr.
10)INJ.METROGYL 500 mg IV /TID.
Day 2:-
10/09/2022
S :. Shortness of Breath
O : Patient is sedated and paralyzed
on AC MV Mode
RR - 18 CPM
FiO2 - 40 %
PEEP - 5 mmHg
TV - 400 ml
I : E - 1: 1.3
BP - 120 / 70 mmHg
PR - 130 bpm
Temp- 101.6 F
spo2 - 99% on RA
CVS-S1,S2 +,no added sounds heard
R/S -BAE+,clear
P/A-soft , non tender
CNS-NAD
GRBS - 108 MG/DL
I/O - 1000/1500 ML
A : NECROTISNG FASCITIS S/P DEBRIDEMENT AND FASCIOTOMY SEPSIS WITH SEPTIC ENCEPHALOPATHY SEPSIS INDUCED CARDIOMYOPATHY AND RESPIRATORY FAILURE
AKI - MODS
P - STOP SEDATION AND PARALYSIS AND ASSESSMENT OF SENSORIUM
Day 3:-
11/09/2022
S :. Patient under sedation
O : Patient is sedated and paralyzed
on SIMV -AC Mode
RR - 18 CPM
FiO2 - 40 %
PEEP - 5 mmHg
TV - 400 ml
I : E - 1: 1.4
BP - 150 / 70 mmHg
PR - 136bpm
Temp- 101.6 F,Inj neomol given >>>101F
spo2 - 98%
CVS-S1,S2 +,no added sounds heard
R/S -BAE+,clear
P/A-soft , non tender
CNS-NAD
GRBS - 168 MG/DL
I/O - 1500/1850 ML
A : NECROTISNG FASCITIS S/P DEBRIDEMENT AND FASCIOTOMY SEPSIS WITH SEPTIC ENCEPHALOPATHY SEPSIS INDUCED CARDIOMYOPATHY AND RESPIRATORY FAILURE
AKI - MODS
P - STOP SEDATION AND PARALYSIS AND ASSESSMENT OF SENSORIUM
TREATMENT:-
1.Inj meropenem 1gm /Iv/TID
2.Inj.Clindamycin 600mg/iv/tid
3.inj lasix 20mg/iv/bd
4.inj .pantop 40mg /iv/od
5.Neb.ipravert and BUDECORT inhalation/6th hrly
6.Inj atracurium 2amp in 46ml NS @5ml/hr
7.Inj midaz @5ml/hr
8.Tab dolo 650mg RT SOS
9.IVF 2 NS,1DNS @ urine output +30ml/hr
10. inj Clexane 40mg SC H/S
11.Tab Ecospirin -AV 75/20mg/RT/OD
12.RT feeds
13.Tab Met-XL 25mg/RT/OD
14.Daily dressing
15.Bp and Grbs monitoring 2nd hrly
16.strict I/O charting
DEATH SUMMARY:-
70yrs old female pt came to casualty with h/o spontaneous bleb formation followed by pricking them and development of cellulitis for which treated outside with debridement and fasciotomy following which patient developed sepsis and sepsis induced cardiomyopathy (on antibiotics and inotropes ,CAG done outside normal coronaries),came LAMA from the outside hospital.At presentation patient vitals Bp-130/90mm Hg; PR -118bpm; RR- 84 cpm.GCS E2V1M4,spo2 88at RR ,94 with 6lit O2,after few hours patient started having worsening hypoxemia and has been electively intubated and connected to MV in view of low GCS and hypoxemia.Started on iv antibiotics,Slow IV fluids based on urine output,diuretics,inotropes, sedatives ,paralytics and thromboprophylaxsis.Serum lactate was 10.
Suregry referral was taken immediately after admission,debridement followed by amputation (sos) was adviced in view of necrotising fascitis but patient attendors have given consent neither for debridement nor for amputation and asked to continue the conservative treatment at their own risk.On 11/9/2022 at 3:30pm patient had fall in HR ,followed by sudden cardiac arrest,4-5cycles of cpr done but patient could not be revived and declared dead at 4:30 pm As ECG showed flat line.
Immediate cause of death : Sepsis with MODS
Antecendent cause:
Necrotising fascitis s/p debridement and fasciotomy
Septic encephalopathy,AKI
Sepsis induced Cardiomyopathy(s/p CAG normal coronaries) and Respiratory failure.
