A 55 year old male Pt came with C/o
Lower backache since 3 weeks radiating to Lt LL
Pt was apparently asymptomatic 3 weeks back since then pt has c/o lower backache which was sudden onset, non progressive, aggravates on movement relieves on rest.
H/o trauma 3 weeks back and was taken to outside hosp and was found to have L5 burst fracture on CT pelvis and came here for further management.
The case was taken over by GM dept I/V/O uncontrolled DM, hyponatraemia and altered sensorium
Past History
H/o PTCA with 2 stents done 18 months back and is on regular medication.
K/c/o DM since 20 yrs and is on T. Metformin 500mg + T. Voglibose 0.20 mg + T.Glimipiride2mg
N/k/c/o HTN, Epilesy, Asthma, CVA
General Examination :
No Pallor, Icterus, Cyanosis, Clubbing, lymphadenopathy, bilateral pedal edema
Pt is on Mechanical Ventilator
GCS- E1V1M1
PR-130bpm
RR-14cpm
BP-100/60 mmhg
@10ml/hr NORAD
@10ml/hr DOBU
ACMV Mode
FiO2 @30
SPO2 99%
RS: BLAE +
Decreased BS in IAA with crepts present in Lt IMA; Rt MA, IMA, IAA
CVS: S1S2 +, No murmurs
CNS:
Tone :Normal B/L both UL&LL
Power : Unable to elicit
Reflexes: Absent B/L in both UL & LL
Brain stem reflexes:
Pupillary reflex- absent
Corneal reflex- absent
Conjunctival reflex- absent
Gag reflex- Present
Occulocephalic reflex- Present
P/A- Soft, NT
I/O 1900/200ml
GRBS 327mg/DL
Clinical Images
3 weeks old L5 burst Fracture & Unstable with PLC injury Planned for L4-L5 S1 Fixation with Heart Failure with Reduced Ejection Fraction (44%) with k/c/o DM since 20 years, k/c/o CAD (PTCA done LAD Lcx Territory) 2 years ago
S/P Post CPR status with chronic calcific Pancreatitis with hyperkalemia with sepsis
Treatment:
As on 1/9/23
1.INJ NORADRENALINE 4ml + 46ml NS @ 10 ml/ hr 2.INJ DOBUTAMINE 1AMP (5ml) in 45ml NS @ 10 ml /hr
3. INJ. Vasopressin 1ml + 39 ml NS @0.4 ml/hr
4. INJ. Midazolam 30ml+ INJ Fentanyl 4ml + 16ml NS @4ml/hr
5.TAB AZITHROMYCIN 500 mg RT/OD
6.NEB WITH BUDECORT + IPRAVANT 6 Th hourly
7.INJ THIAMINE 1 Amp In 100 ml NS IV/BD
8.RT FEEDS 200 ml water 2 nd hourly
200 ml milk 4 Th hourly
9.MONITOR VITALS TEMP; PR; RR ; spo2
10.POSITION CHANGE EVERY HOURLY
11.INJ HAI ACC to GRBS
12.INJ.MEROPENEM 500mg IV/BD
13.INJ HEPARIN 500 IU S.c/ QID
15.INJ LEVIPIL 1gm IV/BD
As on 9/8/23
1.NEB WITH BUDECORT 4th hourly + IPRAVANT 6 th hourly
2. 200 ml 2nd hrly
200 ml milk 4th hrly with protein powder
3. MONITOR VITALS TEMP; PR; RR ; spo2
4.POSITION CHANGE EVERY HOURLY
5.INJ HAI ACC to GRBS
6.INJ.MEROPENEM 500mg IV/BD
7.INJ HEPARIN 5000 IU S.c/ QID
8.INJ LEVIPIL 1gm IV/BD
9. T. ATORVASTATIN + T. ASPIRIN 75/10 MG PO/HS
10. T. OROFER XT PO/OD
11. DAILY DRESSINGS OF BED SORE
12. GRBS monitoring 4th hourly
[31/08/23, 3:44:59 PM] Rakesh Biswas Sir: Please share the post admission transfer events of yesterday in detail as to how and why the patient had to undergo CPR @919676979003 @919573087708
[31/08/23, 3:52:38 PM] Rakesh Biswas Sir: Did he have any recent trauma @919676979003 ?
That's not clear! In the description it's mentioned years and here it's mentioned weeks. Please clarify
[31/08/23, 6:04:12 PM] Cherish Kandru: Yes Sir H/0 trauma (slip and fall from steps) 3 weeks back and also
H/o Rt proximal femur fracture Intramedullary Interlocking nailing done 10 years back
[31/08/23, 6:28:04 PM] Cherish Kandru: Sir the Patient t was shifted from Ortho ward at around 11:30 am in an altered state but the patient was responding when called by his name and obeying commands. At that time the Vitals were
PR-134bpm
BP-60/40mmhg
RR-10cpm
Then Patient was shifted to ICU immediately and ABG and S.Electrolytes were sent.Ionotropic support was started with INJ. DOBUTAMINE and INJ. NORAD. On reporting Sod was found to be 122mEq/L and diagnosis was Altered Sensorium secondary to hyponatraemia. Further Sodium correction was given. After giving correction of 3%Nacl, Sodium was found to be 124mEq/L and patient’s condition didn’t improve. Again Sodium Correction was kept with 3%Nacl @ 30ml/hr. On auscultation grunting was observed and saturations decreased to below 90% with O2 support and also Neb with Budecort and Ipravent was done. Inspite of all these efforts patient’s saturations didn’t improve and continuously decreased to around 78% to 80% and decision to intubate was taken. During intubation Patient went to cardiac arrest and 3 cycles of CPR was done, ROSC was achieved and patient was kept on ventilator ACMV VC mode with FiO2 100%.
[02/09/23, 4:10:15 PM] Rakesh Biswas Sir: Please share all the events that happened around him from falling 3 weeks back to presenting at our hospital
[03/09/23, 10:04:28 AM] Cherish Kandru: Sir the patient fell from staircase 1 month back. Then he had severe pain of lower back radiating to his lower limbs. So he was taken to a nearby hospital in Nalgonda where X-rays and they were told that no fracture was found, he was also taken to another hospital and the same happened again. Then CT scan was done wherein they found the L5 unstable burst fracture with PLC injury and a belt was given to contain the fracture along with some analgesics for the pain. As the patient wasn’t compliant to the treatment given and the pain was severe he was brought to our hospital and he was advised L4 L5 S1 posterior stabilisation.
[03/09/23, 10:08:07 AM] Rakesh Biswas Sir: While the doctors and relatives were throwing their advice around can you share what was happening to the patient every day progressively as he eventually developed altered sensorium and hypotension (?sepsis)?
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