Mortality Audit: ER FEBRUARY 2015

Dominguez, Regine P. 2nd year resident

General Information

• VAA• 14 year old Male• Date of admission: 2/23/15• Chief complaint: difficulty of breathing

History of Present Illness

1 week prior to admission• (+) Carbuncle noted over the scalp• (-) fever, ear discharge, headache and vomiting

3 days prior to admission• (+) Fever Tmax 39, relieved by Paracetamol• (-) vomiting• (+) abdominal pain, dull not associated with food

intake

History of Present Illness

3 days prior to admission• (+)consult at Calalang General Hospital• CBC: Hgb 135, hct 0.41, WBC 11.8, PMN 90, LYM 10 PLT

290, UA:amber, turbid, pH 6.5, sg 1.020, protein 3+, sugar 3+, WBC 10-20, RBC 3-6, given Co-amoxiclav

1 day prior to admission• (+) fever, Last fever episode 4 pm• (+) epigastric pain• (+) difficulty of breathing

History of Present Illness

1 day prior to admission• (+)consult at San Jose Maternity Polyclinic• CBC: Hgb 137, hct 0.41, WBC 7.7, PMN 89, LYM 9 PLT

161, UA:yellow, slightly hazy, pH 5.0, sg 1.030, protein - , sugar 2+, WBC 1-3, RBC 6-8, given Cefalexin

• Patient went home after consult. At home, (+) rashes over upper and lower extremities

• At 3 PM: Patient was brought back to SJMP. • At clinic, (+) tachypnea, and wheezing

History of Present Illness

1 day prior to admission• (+)given Hydrocortisone, Diphenhydramine, Cefuroxime

(100) for three doses, Salbutamol + Ipratropium nebulization done q4

• Despite medication, noted to be tachypneic. • Family was advised transfer. • Prior to transfer: BP 80/50, HR 160, RR 40 O2 sat 85-

99%, conscious, speaks in phrases, warm extremities• (+) one episode of hematemesis

Review of systems

• (-) urinary and bowel symptoms• (-) jaundice• (-) edema• (-) weight loss

Past Medical History

• Primary Koch Infection at 3 months of life, treated for 6 months

• (-) Previous hospitalization• (-) Allergies to food and medication

Family History

• (+) Hypertension, Bronchial Asthma – Maternal• (+) Thyroid disease - Paternal

41 year old Government employee

38 year old Government employee

Birth and Maternal History

• Born to a 24 year old G3P2 (2012) with regular prenatal check-up starting 3 months AOG at Valenzuela General Hospital, with intake of multivitamins, FeSO4, folic acid, Ultrasound : normal; (-)Urinary Tract Infection, Upper respiratory tract infection

• Delivered full term via normal spontaneous delivery by an OB at Valenzuela General hospital, good cry and activity, BW 3.1 kg

• (-) Newborn screening, (-) Hearing screening

Nutritional History

• Breastfed until 3 months• Milk feeding • Complimentary feeding started at 6 months

Developmental History

• Social smile – 2 months• Laughs out loud – 4 months• Creeps and crawls – 7 months• 2 syllables- 1 year• Sits alone – 1 year• Walks with support – 1 year

Personal Social History

• 8 household members• One level house• Well lit, well ventilated• Drinking water – Mineral water• Garbage collection – 3 times in one week• No exposure to second hand smoke• No nearby factories

HEADSS

• H: Lives with both parents, good familial relationship

• E: Grade 8 student, with average grades• A: Loves to play basketball• D: Denies illicit drug use, tried drinking alcohol• S: Denies sexual activity, no girlfriend• S: Goes to church, Prays at night

Physical Examination at the ER• Awake in cardiorespiratory distress• BP 60 palpatory, HR 170s, RR 60s, T 36.8, 02 sat 94• Flushed skin• Anicteric sclera, pink palpebral conjunctiva, (+) alar flaring• Symmetric chest expansion, subcostal and intercostal

retractions, (+) crackles bilateral lung fields• Adynamic precordium, tachycardic, regular rhythm• Globular abdomen, (-) hepatomegaly, tender epigastric pain• Fair pulse

Subjective Objective Assessment Managementcardiorespiratory distressBP 60 palpatory, HR 170s, RR 60s, T 36.8, 02 sat 94Flushed skin, (+) alar flaring, Symmetric chest expansion, subcostal retractions, (+) crackles bilateral lung fieldsAdynamic precordium, tachycardic, regular rhythmGlobular abdomen, (-) hepatomegaly, tender epigastric painFair pulse

CBC: Hgb 144, Hct 43, WBC 11.5, 62, PMN 42, lym 35

ABG: pH 7.25, pco2 32, po2 129, hco3 14, be -12.1, so2 98

Hgt 44

Na 126, K 4.7, Cl 88, Ca 2.06

TB 3.15, DB 2.0, IB 1.11ALT 68, AST 105, BUN 20.8, Crea 253

Septic shock Stereofundin 20 cc/kg

Voluven 20 cc/kg

Standby intubationRefer to ICUInsert IFCD10WStart Meropenem, Vancomycin

Subjective Objective Assessment ManagementAfter Stereofundin and Voluven

BP 100/60, CR 170s, CRT > 3 seconds

Profuse bleeding per Endotracheal tube noted

Dengue blot: Negative

Postintubation ABG: pH 6.81, pcO2 74, pO2 81, SO2 79, BE -22.6

Septic shockPneumonia very severe

Rule out dengue shock syndrome

Voluven at 10cc/kg for 1 hourIntubate at ET size 7 level 13Norepinephrine 0.3

Transfuse 2 u pRBCVitamin K

Subjective Objective Assessment Management2nd hour of ER stay

BP 0, CR 0

BP 110/80, HR 130s, pupils 3-6 mm slowly reactive to light

Septic shock, Pneumonia, very severe

High quality CPRDiscontinue NEGive Epinephrine 2 dosesStart Epinephrine drip

Subjective Objective Assessment Management3rd hour of hospital stay

Profuse bleeding per ET and anterior naresBP 0, CR 0

6 episodes of cardiac arrest noted

5:18 PM, CR 160s5:55 PMBP 0, CR 0

CR 160s

6:13 PMBP 0, CR 0

High Quality CPR

Epinephrine 0.1

CPR 4 minutes,Stereofundin 20cc/kg

CPR 2 minutes, Stereofundin 20 cc/kg CPR 4 minutes, Stereofundin 20

Subjective Objective Assessment Management6:45 PM

BP 0, CR 0

HR 150s7: 13 PMBP 0, CR 0

7:30BP 0, CR 0

CPR for 4 minutesStereofundin at 20 cc/kg

CPR

DNR, DNI status

Mortality Diagnosis

Septic shock, Multiple Organ Dysfunction (Acute kidney Injury, Acute Respiratory Failure, Acute liver injury)

Pneumonia, very severeRule out Dengue shock syndrome