MORTALITY REVIEW

• 75/Malay/gentleman• Not known medical illness?DementiaHistory of MVA on 24/4/13 sustained closed

fracture of Rt humerus and cerebral concussion and was treated conservatively

Patient was bedbound since thenTaking soft diet only

• Presented again casualty on 30/4/13-reduce concious level 1/7 prior to admission-swelling and redness over rt forearm-a/w serous discharge-no fever-no urti-no nausea/vomiting-no uti-no fitting espisode

• Initial assesment• GCS-E4 M5V2• Pupil 2/2 reactiveBp-109/50Pr-110Spo2-100% on FMO2Cvs-DRNMLung-ClearP/A-soft , nontenderRt forearm examination-swollen, redness, warm,blister seen

• Blood ixWbc-11.2Hb-9.8Plt-257Creat-236 (86)Urea-34(5.0)Sodium-151Potassium-3.8Chloride-116

• ABG• ph-7.434• pco2-32.2• Po2-139• Hco3-21.3• Ufeme• Keton-neg• Blood-2+• Prot-1+• Leu-neg

Management by casualty team

• Cxr-clear

Imp-1.Right forearm cellulitis 2.Sepsis secondary to cellulitis 3.right neck humerus fracture 4. Dehydration

Plan•to admit under orthopaedic ward•Iv cloxacillin 500mg qid•Iv c. penicillin 2.4 M qid•To put back slab on rt UL•Strict I/O chart•To refer medical for sepsis•To continue hydration first, for ortho to refer nepro in ward for AKI•X-ray of Rt humerus and radioulnar•Monitor CVP

• 1/5/13• GCS improving-E4, V2m6• Bp-121/53• Pr-90 (less tachycardia)• T-37• Spo2-100• i/o-3250/2300 +950• u/o-90 cc perhr• Urea-21• Creat-131• K-3.6• Na-152

Plan-to insert short line-hydration according cvp keep cvp 8->12 cm-ivd 6 pint nS/24hr-off cloxa and c-pen-iv tazocin 4.5g bd-RP/ABG cm

• 2/5/13Clinically patient still the samePlan-not to put on slab-elevate hand-aspirate blister-cont other mx

• 4/5/13• GCS-e4 v2 m6• Bp-119/57• Pr-68Redness reducingNoted sodium- 161Blood c+s-NG for 3/7Plan-cont iv tazocin 4.5g tds-cont 6 pint alternat HS and D5-to refer medical for hypernatraemia

• Medical review

• 5/5/13GCS-E2V2m4Bp-98/46Pr-85Pt was on HFM 12L/minLung-transmitted soundWbc-8.15Hb-8.1Plt-162

Plan-for CT-brain-iv bisolvan 8mg tds-cont other mx

• 6/5/13GCS-E2V2M4BP-115/50PR-64T-37CT-Brain done-lacunar infarct at lt external capsuleWbc-15Hb-7.9Plt-122Plan-to inform regarding ct-brain finding-to start t.aspirin 150mg od and t.simvastatin

20mg on if no contraindicationDIL/DNR issue to family member-undecided regarding DNRTo d/w again with family member regarding DNRKIV for intubation if GCS worsening

• 7/5/13• GCS-E2, V2 M4• BP-144/56• PR-71• SPO2 100 % on HFM2• Plan• Reinsert CVL• Cont iv tazocin 4.5g tds

• Pm attended by HO• Noted SPO2 drop 80%• Bp-90/39• Pr-98• GCS-e2v3m5• Lung-transmitted sound• No malaenic stool• No bleeding tendency• Dxt-13• Imp-septic shock secondary to cellulitis• Post suction spo2 pick up to 93-.95%• Post run fast I pint bp-100/39

• PLAN• -Cont v/s monitoring• Strict GCS chart• Cont iv tazocin• FBC/RP/ABG/CXR/ECG –to review• Kiv inotrope• Kiv intubate

• S/B MO• Case noted• Gcs-E2V2M5• BP-80/40• PR-90• ECG-notedPlan-start ivi dopamine-trace ix-cxr

• Wbc-15.6• Hb-7.8• Plt-142• Urea-11.1• Creat-70• Sodium-156• K-3.4• Chloride-124• ABG-

• 8/5/13• Gcs-E3V2M5• BP-110/56• PR-110-on iv noadrenaline and iv dopamine• p/a-soft• Lung-transmitted sound

• Plan• Cont iv tazocin D6• Cont other mx

• Pm• Spo2 drop 56%• Bp drop-60/30

s/b MODIL and DNR issue

Plan-cont HFM2 15L/MIN-cont inotrope-not for escalation-cont antibiotic-cont ivd

• 9/5/13• GCS-7/15• Tachypnea• Bp-111/46• Pr-140• Spo2-95%• T-37• i/o-1241/945-+296

• Plan• Cont iv tazocin• Cont HFM2• Cont inotrope support

• 10/5/13

• GCS-E2V2M3• BP-109/78• PR-152• SPO2-99• Lung-transmitted sound• p/a-soft, not distended

Plan-cont current mx

• 11/5/13• GCS-E2V2M2• BP-116/49• PR-127• P/A-soft, not distended

• Plan• cont current mx

• 12/5/13• GCS-E1M1V1• BP-101/33• PR-112• SPO2-99• P/A-soft, not distended

• Plan-cont current mx

• 13/5/13• 2.40 am• Pt asystole

• Was refer to medical in casualty for AKI-to continue hydration and to refer nephro