80 year old female with ARDS WITH HEART FAILURE WITH LEFT PNEUMOTHORAX WITH AKI WITH MI WITH MODS

April 18, 2022

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Case: A 80 year old female patient resident of suryapet,came with complaints of

1)shortness of breath since 3days

2) cough since 3 days

HISTORY OF PRESENTING ILLNESS:

Patient was apparently asymptomatic 3 days back and later developed shortness of breath and cough associated with pain in chest and was taken to an rmp ,where she was given symptomatic treatment after 3days of starting of complaints and then was referred to the hospital.

Patient is a known case of hypertension on telmisartan 40mg

Not a known case of diabetic.

HISTORY OF PAST ILLNESS:

Patient was admitted in the hospital for 3 days with similar complaints 6months back and was given cardarone bd and dabilong bd,tab dytor plus

Patient was diagnosed with persistent Atrial fibrillation with controlled ventricular rate ,Decompensated Heart failure outside the hospital.Patient continued the same medication regularly.

There is no history of DM/EPILEPSY/ASTHMA/CVA.

History of fall and fracture to right wrist 1month back and referred to orthopaedic for which she was given NSAIDS,she continued use of NSAIDS till present day.

Treatment history:Patient was on medication as follows

1.Tab. cardarone(amiodorone HCl) 200mg bd

2.T.Dabilong(dabigatran etixilate mesylate) 110mg bd

3.T.dytor plus -ls(spirinolactone and torasemide) 10mg od

Along with that she used NSAIDS for wrist fracture since 1month.

PERSONAL HISTORY:

Appetite -decreased since 1 week

Bowel and bladder-Regular

Micturition-normal

Addictions-no

FAMILY HISTORY-no significant family history.

SERIES OF EVENTS IN OUR HOSPITAL

Patient was brought to casualty with complaints of sob and cough associated with chest pain since 3days.

Patient is a known case of AF and heartfailure on regular medication.

On EXAMINATION.

Cvs-s1s2 heard

Rs-bae +b/l crepts+

P/a -soft

Bp-100/70mmhg

Spo2-80% with 15lit O2

Immediately Abg was taken and showed metabolic acidosis with type 2 respiratory failure

2d echo was done and showed-Dilated Ra/RV/ivc,moderate to severe pulmonary artery hypertension.

Chest x ray was done -cardiomegaly?,left and right sided pneumonia most probably ARDS.

RAT-Negative

Patient connected to CPAP With Fio2 -100% and saturation was still 82%

IN View of falling saturation patient was premedicated with inj.Midaz 2cc,inj atracurium 1amp.patient was preoxygenated and patient was kept in rose position and et tube of size 7.0 introduced and fixed at 22 @11:25am

Patient suddenly developed bradycardia and asystole for which 6cycles of cpr initiated acc to 2020 AHA guidelines.ROSC achieved ,cpr discontinued and patient connected to MV with ACMV-VC mode,Fi02-100%,PEEP-5cms of H20,VT-420ML,RR-14,BP-100/50MMHG,PR-130Bpm,RS- Decreased air entry on left side,cvs-s1s2.

ECG showed vT.abd inj.Amiodarone 150mg iv stat given,inj norad 1amp in 50ml Ns @10ml /hr started.

Inspite of the above settings and et tube in place,sp02 was above 70% and on ausculatation showed decreased breath sounds on left side.

Chest x-ray showed left pneumothorax @1:00pm pulmonology consultation was taken and tube thoracostomy was done ICD was placed on 5th ICS with 20french at mark 10 at 1.10pm

No complaints of cough ,hemoptysis ,abdominal distension,decreased urine output,wheeze.

GCS-E0V1M0.

PROVISIONAL DIAGNOSIS

ARDS WITH HEART FAILURE WITH LEFT PNEUMOTHORAX WITH AKI WITH MI WITH MODS.

Treatment

1)Inj.piptaz 4.5 gm iv stat followed by inj.piptaz -2.25gm iv tid

2)Tab.azithromycin 500mg through RT

3)INJ.Pan 40mg iv oD

4)Nebulisation

5)Inj. NORAD 2amp in 50ml NS @20ML/HR

6)INJ MIDAZ -5ML /HR

7)INJ. ATRACURIUM 1amp IN 38ML NS @2ML /HR