CASE PRESENTATION DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE 1 - - PowerPoint PPT Presentation

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CASE PRESENTATION DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE 1 - - PowerPoint PPT Presentation

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CASE PRESENTATION DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE 1 CHIEF COMPLAINTS Pt brought to the EMD with complaints of 1)shortness of breath since 1 day 2)fever since 3 days 2 VITAL SIGNS Pulse rate 119/min Blood pressure 110/60 mmHg

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CASE PRESENTATION

DR.K.V.RAMANA II YR PG EMERGENCY MEDICINE

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CHIEF COMPLAINTS

Pt brought to the EMD with complaints of 1)shortness of breath since 1 day 2)fever since 3 days

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VITAL SIGNS

Pulse rate 119/min Blood pressure 110/60 mmHg Respiratory rate 24/min Temperature 100 F Pain nil

GRBS 252 mg/dl

ON ARRIVAL GCS E4 V5 M6 SPO2 82% WITH RA(0.2)

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PRIMARY SURVEY

AIRWAY

UNABLE TO SPEAK FULL SENTENCES

BREATHING

TACHYPNEIC 02 SATURATION : 82% WITH RA (FiO2 : 0.2) NO CYANOSIS

CIRCULATION

NORMOVOLEMIC ( BP 110/60 MMHG) CAPILLARY REFILL TIME (<3 SEC)

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HISTORY

  • A 55 yr old female,housewife,resident of

Nakrekal village brought to the EMD with complaints of shortness of breath since 1 day, grade III, sudden onset,associated with B/L pedal edema since 3 days and decreased urine output since 1 day.

  • No history of chestpain,palpitations,syncope,
  • rthopnea.
  • No history cough, noisybreathing,expectoration.

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  • History of fever, high grade with chills

and rigor associated with burning micturition and dysuria and incresed frequency since 3 days.

  • And mild abdominal pain,diffuse in

nature not associated with vomiting,diarrohea or abdominal distension.

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  • Past medical illness : K/C/O of type 2

diabetes mellitus(NIDDM).

  • Past surgical illness : History of right

great toe amputation(? Diabetic foot)

  • Medications : Using METFORMIN 500

mg BD

  • Family history : Not significant

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General: Conscious, unable to lie comfortable on bed due to distress. Head: Atraumatic,normocephalic Eyes: Normal size pupils reacting to light,no pallor ,no icterus Ears: Normal tympanic membranes Nose: No discharge Secondary survey

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Neck: jugular venous distension present, no stridor,no cervical lymphadenopathy Pharynx: Tongue dry, normal dentition, no lesions,no swelling Chest: B/L symmetrical,non tender, no deformity. Lungs: B/L air entry equal,no added sounds

Secondary survey

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Heart: Tachycardia (119/min), rhythm regular, no murmurs, no rubs, or gallops. Abdomen: Diffuse abominal tenderness with right flank predominant tenderness with right costovertebral angle tenderness present ,no mass felt ,no guarding or rigidity. Urogenital: Burning micturition present ,decreased urine output, no discharge.

Secondary survey

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Extremities: Normal pulses, no neuro deficits. Back: Right costovertebral angle tenderness present Neuro: Normal sensation, strength; normal reflexes and gait, Skin: Normal Lymphatic system: No generlized/local lymphadenopathy.

Secondary survey

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DIFFERENTIAL DIAGNOSIS

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K/C/O NIDDM,HIGH SUGARS,DYSPNEA ? UTI/PYELONEPHRITIS,MILD ABDOMINAL PAIN

DYSPNEA,B/L PEDAL EDEMA, RAISED JVP,K/C/O NIDDM,TACHYCARDIA K/C/O NIDDM,BL PEDAL EDEMA, DECREASED URINE OUTPUT SUDDEN ONSET DYSPNEA,B/L LIMB SWELLING,TACHYCARDIA,CLEAR LUNGS

FEVER,BURNING MICTURITION,ABDOMINAL PAIN, COSTOVERTEBRAL ANGLE TENDERNESS,INCREASED FREQUENCY,TACHYCARDIA

DIABETIC KETOACIDOSIS

CONGESTIVE CARDIAC FAILURE(CORPULMONALE) ACUTE/CHRONIC KIDNEY INJURY

ACUTE PULMONARY EMBOLISM

UROSEPSIS (UTI/ACUTE PYELONEPHRITIS)

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INVESTIGATIONS

ECG ABG CHEST X RAY 2D ECHO CBP RFT LFT CUE BLOOD AND URINE C/S COAGULATION PROFILE USG ABDOMEN URINE FOR KETONES HIV,HBsAG,HCV HbAIC RBS BLOOD GROUPING LOWER LIMB DOPPLER

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ECG

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  • After initial ECG showing sinus

tachycardia and S1Q3T3 pattern.

  • Pt been advised for SPIRAL CT with

pulmonary angiography, D dimers.

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Event analysis (16/12/2017,1;20am)

  • Patient developed severe respiratory

distress after shifting from CT room.

  • In the view of respiratory failure patient is

intubated with endotracheal tube 7.5mm, cuff inflated and after confirming B/L air entry equal with five point auscultation fixed at 22 cm lip mark.

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  • And connected to mechanical

ventilator with initial settings

  • MODE : IPPV
  • FREQUENCY : 16/MIN
  • FIO2 : 100 %
  • TIDAL VOLUME : 400 ML
  • PEEP : 0 CM H20
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EVENT ANALYSIS(16/12/2017,1:40 AM)

  • Pt ECG monitor suddenly showing no

electrical activity with absent central and peripheral pulses , so immediately CPR initiated according to ACLS 2015 guide lines.

  • After 6 min of CPR (each cycle 30

compressions plus 2 rescue breaths) plus inj adrenaline intra tracheal ) patient achieved ROSC with PR : 124/min, blood pressure 100/50 mmHg,SPO2 95% )

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Post CPR care : 1)IV fluid bolus @ 20 ml/kg 2)Inj. MANNITOL 1gm/kg iv stat 3)Inj. DOBUTAMINE 5 mic/kg/min continous infusion.

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Event analysis(16/12/2017,2:00 am)

Narrow complex tachycardia with absent P waves regular rhythm Supraventricular tachyardia noticed

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  • ECG showing supraventricular tachycardia

with hemodyanmic unstability.

  • So immediately cardioversion with 50 J

given.

  • Rhythm reverted back to normal sinus

tachycardia.

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Investigations(day of admission)

CBP Hb 9.3gm/dl WBC 40,000/cumm platelets 1.52 lakhs/cumm Blood group O/ Rh positive Coagulation profile PT 19 sec INR 1.45 APTT 39 sec HBA1C 7.6%

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ARTERIAL BLOOD GAS ANALYSIS PH 7.34 PCO2 22 PO2 112 HCO3 11 BE

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Metabolic acidosis with compensatory respiratory alkalosis

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Investigations(day of admission)

RENAL FUNCTION TESTS Blood urea 104 mg/dl Serum creatinine 2.2 mg/dl Na 119 mmol/l K 4.5 mmol/l Cl 81 mmol/l LIVER FUNCTION TESTS Total bilirubin 1.58 mg/dl Direct bilirubin 0.59 mg/dl SGOT 81 IU/L SGPT 60 IU/L ALK PHOSPHATE 274 IU/L ALBUMIN 2.8 gm/dl

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Urine examination SG 1.010 PH acidic SUGARS ++++ ALBUMIN + COLOUR Pale yellow BILESALTS/ PIGMENTS Absent/negati ve PUS CELLS 15-16 CASTS/ CRYSTALS nil

HIV NONREACTIVE HBSAG NON REACTIVE HCV NON REACTIVE

Urine for ketones - negative

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2D ECHO :

  • Right atrial and ventricular dilatation.
  • IVC disteneded
  • OS ASD
  • Good LV function
  • EF : 58%

USG ABDOMEN : emphysematous pyelonephritis right kidney LOWER LIMB DOPPLER : NORMAL STUDY

D DIMERS : 200 -400 ng/ml

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CHEST X RAY

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CT CHEST

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CT ABDOMEN

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Final(complete) diagnosis

  • Empysematous pyeloneorhitis with

septic shock

  • Venous gas embolism with

respiratory failure.

  • With acute kidney injury(AKI)
  • K/C/O type 2 diabetic mellitus
  • Ostium Secundum

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PROBLEM BASAED APPROACH

I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK

  • II. VENOUS GAS EMBOLISM WITH RESPIRATORY

FAILURE

  • III. ON MECHANICAL VENTILATION
  • IV. AKI ( SECONDARY TO PYELONEPHRITIS)
  • V. COAGULOPATHY
  • VI. HYPONATREMIA(? Hypovolemic

hyponatremia) VII.K/C/O OF TYPE 2 DIABETES MILLITUS VIII.POST CPR STATUS

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1.INJ.IMIPENEM CILASTIN 500MG IV BD 2.INJ.LEVOFLOXACIN 500MG IV BD 3.CENTRAL VENOUS ACCESS SECURED 4.INJ .NORADRENALINE 0.02MIC/KG/MIN WITH TARGET MAP >65 MMHG 5.Urology consulation done.

I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK

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1.OXYGEN THERAPY WITH INVASIVE RESPIRATORY SUPPORT 2.INJ.UNFRACTIONED HEPARIN 5000 IU SC QID 3.VENTILATORY SETTINGS MODE : IPPV FREQUENCY : 16/MIN FIO2 : 80 % TIDAL VOLUME : 400 ML PEEP : 0 CM H20

II&IIIVENOUS AIR EMBOLISM WITH RESPIRATORY FAILURE

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  • MAINTAIN TARGET MAP >65 mmHG
  • MONITOR URINE OUTPUT /HOUR
  • INJ. FURESOMIDE 20 MG IV BD IF MAP >65

MMHG

  • NEPHROLOGIST OPINION AND PLAN FOR

HEMODIALYSIS IF SYMPTOMS WORSENS.

  • 3 units FRESH FROZEN PLASMA infused.
  • IV. AKI ( SECONDARY TO PYELONEPHRITIS)

V.COAGULOPATHY(DIC)

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  • INJ.HUMAN ACTRAPID

(ALBERTS REGIMEN: GIK REGIMEN)

  • GRBS MONITORING EVERY 4TH HRLY
  • SUPINE POSITION,HEAD NEUTRAL & FLAT
  • TEPID SPONGING AND AVOID HYPERTHERMIA
  • IV FLUIDS 0.9 NS @ URINE OUTPUT PLUS

50ML/HR

  • INJ DEXAMETHASONE 4MG IV TID
  • VI. TYPE 2 DIABETES MELLITUS(NIDDM)

VII.POST CPR STATUS

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  • INJ.RANITIDINE 50MG IV BD
  • INJ.ONDANSETRON 4MG IV SOS
  • Rt feeds @25 kcal/kg/min (100 ml/hour 2nd

hrly)

  • Regular ET/ORAL suction 2nd hrly
  • Position change 2 nd hrly
  • Limb and chest physiotherapy
  • With contnous monitoring of HR,MAP,URINE

OUTPUT,SPO2,TEMPERATURE.

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DAY 2 (17/12/2017)

  • Patient on mechanical ventilator with

GCS E4 VT M6

  • On mechanical ventilatory support

VITAL SIGNS

Pulse rate 114/min Blood pressure 110/60 mmHg Respirate rate 16/min ON M.V. Temperature 99 F

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INVESTIGATIONS(DAY 2)

Renal function tests Blood urea 131 mg/dl Serum creatinine 3.2 mg/dl Na 129mmol/l K 3.9 mmol/l Cl 93 mmol/l Liver function tests Total bilirubin 5.94 mg/dl Direct bilirubin 3.79 mg/dl SGOT 184IU/L SGPT 122 IU/L ALK PHOSPHATE 225IU/L ALBUMIN 2.9gm/dl

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PROBLEM BASAED APPROACH (DAY 2)

I. EMPHYSEMATOUS PYELONEPHRITIS WITH SEPTIC SHOCK

  • II. VENOUS AIR EMBOLISM WITH RESPIRATORY

FAILURE

  • III. ON MECHANICAL VENTILLATOR
  • IV. AKI ( SECONDARY TO PYELONEPHRITIS)
  • V. HEPATOCELLULAR DYSFUNCTION
  • VI. K/C/O OF TYPE 2 DIABETES MILLITUS

VII.CRITICALLY ILL /ICU CARE

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  • SAME TREATMENT CONTINUED AS DAY 1
  • INJ .NORDRENALINE 0.01 MIC/KG/MIN

CONTINOUS INFUSION

  • INJ.HEPAMERZ 5 GM IV BD
  • INJ.N ACETYL CYSTEINE 400 MG IV TID
  • TAB.UDILIV 300MG RT BD

HEPATOCELLULAR DYSFUNCTION

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Day 3 (18/12/2017)

  • Patient on mechanical ventilator with GCS E4

VT M6. VITAL SIGNS Pulse rate 78/min Blood pressure 110/70 mmHg Respirate rate 16/min Temperature 99 F

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Day 3 (18/12/2017)

Patient on mechanical ventilator for 3 days and weaned off successfully on 18/3/2017

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  • SAME TREATMENT CONTINEUED AS

DAY 2

  • INJ. NORADRENALINE TAPPERED

OFF.

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Day 4 (19/12/17)

  • DAY 4 UNEVENTFUL
  • BLOOD CULTURE SHOWS NO GROWTH .

Urine cultures showing >105 CFU/ml Significant growth Escherichia coli isolated

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  • ANTIBIOTICS SHIFTED ACCORDING TO

SENSITIVITY.

  • TAB.NITROFURONTOIN 100 MG BD

STARTED.

  • OXYGEN SUPPLEMENTATION 4 LIT/MIN

FLOW VIA VPD .

  • REMAINING TREATMENT CONTINEUD AS

SAME ABOVE.

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  • Remaining days were uneventful.
  • Orthopedic referral done in view of right

hip pain since 1 month advised gait training.

  • Ophthalmology referral done in view of

blurring of vision .shows moderate non proliferative diabetic retinopathy with normal disc margin. No signs of

  • papilledema. Advised for glycemic

control.

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Final diagnosis

  • ACUTE EMPHYSEMATOUS PYELONEPHRITIS
  • COMPLICATING TO VENOUS GAS EMBOLISM
  • SEPTIC SHOCK
  • AKI
  • HEPATOCELLUALR DYSFUNCTION.
  • NIDDM WITH MODERATE DIABETIC

RETINOPATHY.

  • OSTIUM SECUNDUM ATRIAL SEPTAL DEFECT

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Patient discharged on 03/01/2018

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L.A.M. Andrade, S.S. Collazos, M.A.M. Ferretiz, B. Ruiz, M.F.C. Vazquez, et al.Emphysematous pyelonephritis, case report and review of the literature MOJ Clin Med Case Rep, 3 (3) (2015) 00066

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