DEATH SUMMARY

Selvaraj , 41/m ,g107311

Cause of death: polytrauma with sepsis/DIC/MODS/AKI
DOA;22/8/14
DOS:23/8/14-WD+ext fixation 28/8/14-WD
DOD: 2/9/14
Alleged history of RTA on 21/8/14 at 8pm. Sustained injury to left lower limb and l
upper limb. Referred from outside as left lower limb degloving injury with h/o ear
bleed.
No h/s/o injury to other organs
No h/o seizures/loc/vomiting
h/o pulmonary TB 4 months ago- defaulter (1 month treatment)
h/o seizures 4 yrs back- not on any medications
O/E- pt was conscious , oriented, on left lower limb Thomas splint, pallor +
Chest and pelvis compression test negative
90/60mmhg RR-24/min

PR-112/min

BP-

CVS, RS}NAD
U/O adequate
Investigations:
USG abdomen- minimal ascited
Xray left ll- open type 3b prox 1/3rd l tibia #
Type 2 open r.medial malleolus #
Type 1 open l. lateral condyle#
On 22/8/14 patient developed hypotension and tachypnea. Patient was conscious
responding to oral commands.
Vitals:
Pulse not palpable
BP-80/40?
SpO2-92%
RS- b/l creps

Patient had become disoriented around 1:10 pm and developed gasping and
sweating (spo2 66%) following which ccu team was called. At 1:20 pm ccu resident
arrived . 2 large bore iv cannulas were secured and 1 pc was started.
PR-128/min BP-90/60 mmhg SpO2 by mask-95%. At 1:40 pm he was intubated by
sedation with inj. Midazolam 2mg iv and connected to ambu bag. As the patient was
breathing spontaneously he was put on t-piece
Vitals improved thereafter. Pt was shifted to ground floor casualty.
ABG s/o metabolic acidosis
Hb-7.0
Pt-24.6

diagnosis-s/o DIC

Inr-2.0
FDP-+ve
Plts- 82000
Patient was reviewed again by the ccu team. Advised to correct acidosis by 100
meq NaHco3 in 100 ml NS. Patient taken over in ccu on the same day. Was
connected to SIMV mode on the ventilator . as he was delivering low tidal volume he
was re-intubated again.
Course in ccu:
On arrival patient was conscious restless. Was maintaining 95% saturation with FiO2
of 50-100%. On auscultation b/l creps and wheeze was present.
Vitals: PR-130/min

BP-80/40

CVP-3-4cmh2o

u/o- 40 ml/hr

Was started on dopamine 5g/kg/min infusion. Patient was posted for surgery on
23/8/14 for wound debridement and external fixation.
Hb-9.7 platelets-2,00,000. After stabilizing the patient he was taken up for surgery
in EMS OT.
Intra op:
Induced with fentanyl 60+30mg , ketamine 50mg ,atracurium 30mg, sevoflurane
4%
Inj.calcium gluconate 2g iv, morphine 7 mg, txa 1g was given.
Dopamine infusion @6ml/hr, noradrenaline infusion @0.1ml/hr were started. Blood
loss during the procedure was1.5l and urine output was 200ml. 4 platelets 3 ffps 1
cryoprecipitate were transfused. Patient was shifted back to ccu in view of
hemodynamic instability for elective extubation. Patient regained his sensorium
after a while, was put on ASV mode with fio2 40%. Vitals were stable.
Blood culture and tracheal culture reports were sterile. Ooze from operated site+.

Patients general condition was sick throughout. He had a fever spike on 24/8/14
(38.8 c). after multiple transfusions his Hb came to 9.4, INR continued to be high
(2.0). metabolic acidosis had resolved( ph 7.4 lac-2.1).
Tracheal aspirate culture had turned positive for A.Baumanii and E.coli sensitive to
ciprofloxacin, amikacin, magnex and gentamycin. Inj Magnex 2g iv bd was started
along with amikacin 500mg bd and inj flagyl 500 mg bd. On 25/8/14 CTVS opinion
was obtained for feeble distal pulse. No active intervention was advised. Frequent
fever spikes were noted. He had developed hypernatremia on 26/9 & was given 5%
D@ 100ml/hr to correct the same through RT.
Inj NA @ 10ml/hr as SVR was low. Cardiac output was progressively increasing.
Plastic surg opinion was obtained on 26/8- was advised to post the patient after
hemodynamic stabilization as the wound was infected. Patient was started on TPN@
75ml/hr.
Hemoglobin was persistently low . improved only with blood transfusion. As the
patients blood group was B-ve which was not available O-ve blood was transfused.
Over 20 pc were transfused. Eventually even O ve blood became unavailable. FFPs
and cryos were also transfused in accordance with the PT INR values. On 28/8
patient was taken up for debridement in EMS OT. Blood loss was 500ml.
Patients general condition continued to be sick. Blood culture reports sterile.
Wound swabc/s-pseudomonas sensitive to cipro and magnex following which
amikacin was stopped and cipro was started on day 11 of ccu stay.
On 30/8 patient became tachypnoeic and BP dropped to 90/60 mmhg and HR140/min. ABG showed hypokalemia. Potassium correction and adrenaline infusion
@4ml/hr was started. Colloid 250 ml stat was given. Febrile spikes continued to
occur and u/o reduced.
On 1/9/14 BP dropped to 70/30 mmhg. GCS became poor E2M2V T. spo2 -88%. Ph6.9. inj NaHco3 was started at 100meq /hr for acidosis correction and inj
vasopressin was started at 2ml/hr.
On 2/9/14 @ 7am BP dropped to 60/40 HR-80/min. inj soda bicarb60mg, inj calcium
gluconate 1gm iv and glucose+ insulin infusion was started. Meanwhile BP further
dropped to 40/15mmhg and HR-10/min following which CPR was started.inj
adrenaline 1mg iv stat was given. Et tube bleeding+.
@7:30am BP-40/20mmhg- cpr started- ecg showed changes s/o VF-DC shock given.
No ROSC. Inj amiodarone 300mg iv, inj adrenaline 1mg and DC shock given. No
ROSC.
Declared dead @8am on 2/9/14