DIAGNOSIS
ACUTE DECOMPENSATED LIVER DISEASE SECONDARY TO ALCOHOL WITH GRADE 2 HEPATIC ENCEPHALOPATHY
CASE FINDINGS
- C/O DRAGGING TYPE OF PAIN OF B/L LOWER LIMBS SINCE EVENING
- DECREASED URINE OUTPUT SINCE 15 DAYS
- ABDOMINAL DISCOMFORT SINCE 15 DAYS
C/O SWELLING OF BILATERAL LOWER LIMBS SINCE 15 DAYS
PATIENT WAS APPARENTLY ASYMPTOMATIC 15 DAYS AGO AND THEN DEVELOPED SWELLING OF BOTH LOWER LIMBS, INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, AND ABDOMINAL DISTENSION SINCE 15 DAYS
ABDOMINAL DISCOMFORT SINCE 15 DAYS
C/O DECREASED URINE OUTPUT SINCE 15 DAYS
H/O SEIZURES, 3 EPISODES- ONE IN DEC 2021, JAN 2022, SEP 2022
NOT USED ANY MEDICATION
TONIC SEIZURES, UPROLLING OF EYES +, FROTHING FROM MOUTH +
POSTURAL CONFUSION + FOR 15 MINUTES
SPONTANEOUS URINATION -
SPONTANEOUS DEFECATION -
VOMITINGS -
LOOSE STOOLS -
INCREASED DAYTIME SLEEPINESS SINCE 1 WEEK
H/O INCREASED BILIRUBIN LEVELS 1 MONTH BACK
HYPERPIGMENTED PATCHES (DIFFUSE) PRESENT OVER THE BODY
PAST HISTORY
NOT A KNOWN CASE OF HTN, DM, ASTHMA, TB, EPILEPSY
PERSONAL HISTORY
DIET- MIXED
APPETITE- NORMAL
BOWEL AND BLADDER MOVEMENTS- REGULAR
SLEEP- ADEQUATE
ADDICTIONS- CHRONIC ALCOHOLIC SINCE 20 YEARS
FAMILY HISTORY
NO SIGNIFICANT FAMILY HISTORY
General examination
Done after obtaining consent, in the presence of attendant with adequate exposure
Patient is conscious, coherent, cooperative and well oriented to time, place and person
Patient is well nourished and moderately built
Vitals
Temperature- Afebrile
Blood pressure- 90/70 mmHg
Pulse rate- 82 bp
Respiratory rate- 18 cpm
SPO2- 98%
GRBS- 126 mg%
SYSTEMIC EXAMINATION
Local examination
Abdominal examination:
Inspection
Shape of the abdomen- Distended
Umbilicus- everted
Movements of abdominal wall- moves with respiration
Skin is smooth, shiny
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites
Palpation
Inspectory findings are confirmed
Fluid thrill positive
Abdominal girth at the level of umbilicus is maximum
Percussion
Fluid thrill- felt
Auscultation
Bowel sounds are decreased
Cardiovascular system examination:
S1 and S2 sounds are heard
No murmurs
Respiratory system examination:
Bilateral air entry present
Normal vesicular breath sounds are heard
Central nervous system examination:
No focal neurological deficits
DEATH SUMMARY
A 44 YEARS OLD MALE, CAME TO CASUALTY WITH COMPLAINTS OF ABDOMINAL DISCOMFORT SINCE 15 DAYS, DECREASED URINE OUTPUT SINCE 15 DAYS AND DRAGGING TYPE OF PAIN OF BILATERAL LOWER LIMBS SINCE EVENING
INITIAL INVESTIGATIONS WERE DONE AFTER CLINICAL EXAMINATION OF THE PATIENT AND PATIENT WAS DIAGNOSED WITH ACUTE DECOMPENSATED LIVER DISEASE, SECONDARY TO ALCOHOL GRADE 2 HEPATIC ENCEPHALOPATHY WITH AKI SECONDARY TO RIGHT LOWER LIMB CELLULITIS, AND MANAGED SYMPTOMATICALLY AND RYLES TUBE WAS PLACED AND DIAGNOSTIC ASCITIC TAP WAS DONE
AT 2:00 PM, HIS BP WAS NOT RECORDABLE AND PATIENT WAS STARTED ON IONOTROPES TO MAINTAIN BP, BUT STILL HIS BP WASN'T MAINTAINED EVEN ON TRIPLE IONOTROPIC SUPPORT AND AROUND 5:00 PM, ABG WAS DONE SHOWING SEVERE METABOLIC ACIDOSIS, AND BICARBONATE CORRECTION WAS GIVEN, BUT STILL ACIDOSIS IS PERSISTING AND AROUND 9:00 PM, PATIENT HAS BEEN INTUBATED IN VIEW OF FALLING GCS AND FALLING SATURATIONS
POST INTUBATION VITALS: HIS BP IS NOT RECORDABLE AND HIS PULSE RATE IS AROUND 120 BPM
PATIENT GRADUALLY DEVELOPED BRADYCARDIA AND SUDDENLY WENT INTO CARDIAC ARREST, FOLLOWED BY WHICH CPR WAS DONE FOR 30 MINUTES, ACCORDING TO AHA GUIDELINES, FOLLOWED BY WHICH PATIENT COULDNOT BE REVIVED AND DECLARED DEAD AT 10:25 PM ON 29/10/22 AS A FLAT LINE WAS OBSERVED ON ECG
CAUSE OF DEATH
IMMEDIATE CAUSE OF DEATH- REFRACTORY HYPOTENSION SECONDARY TO SEPSIS
ANTECEDENT CAUSE OF DEATH- SEPSIS WITH MODS, RIGHT LOWER LIMB CELLULITIS
ACUTE DECOMPENSATED CHRONIC LIVER DISEASE, ?ESOPHAGEAL VARICEAL BLEEDING
AKI SECONDARY TO SEPSIS WITH GRADE 2 HEPATIC ENCEPHALOPATHY
TREATMENT
29/10/22 (8:00 AM)
1. RT FEEDS WITH 100 ML MILK + 200 ML FREE WATER 2ND HOURLY
2. TAB. PENTOXYPHYLLINE 400 MG/PO/BD
3. TAB. LASIX 40 MG/PO/BD
4. TAB. SPIRANOLACTONE 25 MG/PO/OD
5. SYP. LACTULOSE 30 ML/PO H/S
6. TAB. UDILIV 300 MG/PO/BD
7. TAB. RIFAGUT 550 MG/PO/BD
8. INJ. CEFOTAXIM 2GM/IV/BD
29/10/22 (2:00 PM)
1. STARTED ON IONOTROPES
INJ. NORADRENALINE 2 AMP IN 46 ML NS @ 8 ML/HR INCREASE/DECREASE TO MAINTAIN MAP OF 65 MMHG
LATER AROUND 4:00 PM BP HASN'T PICKED UP, EVEN AFTER MAXIMUM OF NORADRENALINE
THEN VASOPRESSIN HAVE BEEN STARTED
29/10/22 (6:00PM)
1. PLAN FOR ELECTIVE INTUBATION IN V/O LOW GCS
2. INJ. NORADRENALINE 2 AMPLES + 46 ML NS @ 24 ML/HR
3. INJ. VASOPRESSINE 1 AMPOULE IN + 49 ML NS @ 2 ML/HR
4. INJ. DOBUTAMINE 25 MCG (5M) + 45 ML NS @ 3.6 ML/HR
5. INJ. SODIUM BICARBONATE 100 MEQ STAT IV
6. INJ. 100 MEQ OF SODIUM BICARB IN 100 ML NS OVER 1 HOUR
7. INJ. SODABICARBS 25 MEQ IN 50 ML NS OVER 30 MIN
29/10/22 (9:00 PM)
PATIENT WAS INTUBATED WITH ET 7.5 AFTER PASSING BUJIE POSITION WAS CONFIRMED WITH 5 POINT PROFILE AUSCULTATION
PRE OXYGENATION FOR 3 MINUTES DONE
PRE INTUBATION MEDICATION
INJ. MIDAZ 3 CC IV GIVEN
INJ. ATRACURIUM 1CC IV GIVEN
INJ. ONDEN 4 CC IV GIVEN
POST INTUBATION VITALS
HR- 120 BPM
BP- NOT RECORDABLE
CVS- S1, S2 +
R/S- B/L AIR ENTRY PRESENT
RIGHT INFRA AXILLARY CREPTS +
AFTER 20 MINUTES OF INTUBATION
THERE WAS A SUDDEN FALL OF HEART RATE
HR- 42 BPM
SPO2- 34%
PATIENT WAS ARRESTED IN VIEW OF WHICH CPR WAS INITIATED
29/10/22 (9:55 PM)
DUE TO SUDDEN FALL IN HEART RATE AND SATURATION SPO2 35 MM OF HG AND SUDDEN CARIDAC ARREST, CPR WAS INITIATED ACCORDING TO AHA GUIDE LINES
BP NOT RECORDABLE, PULSE NOT RECORDABLE, INJ. ADRENALINE 1CC IV GIVEN, CPR INITIATED
29/10/22 (10:00 PM)
BP & PR NOT RECORDABLE
INJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED
29/10/22 (10:05 PM)
BP & PR NOT RECORDABLE
INJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED
29/10/22 (10:10 PM)
BP & PR NOT RECORDABLE
INJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED
29/10/22 (10:15 PM)
BP & PR NOT RECORDABLE
INJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED
29/10/22 (10:20 PM)
BP & PR NOT RECORDABLE
INJ. ADRENALINE 1 CC/IV GIVEN CPR CONTINUED
29/10/22 (10:25 PM)
BP & PR NOT RECORDABLE
DESPITE OF CONTINUOUS RESUSCITATIVE EFFORTS PATIENT COULD NOT BE REVIVED AND DECLARED DEATH AT 10:25 PM ON 29/10/22
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