48 year old with complaints of VOMITINGS ,loose stools ,SOB

 45 Year old male came with chief complaints of vomitings,loose stools,sob since morning

On presentation patient tachypneic with hypoxia with BP 80/50 mm hg with distended abdomen and pedal oedema  

Vomitings - bilious ,non projectile ,water as content 

Loose stools - watery stools ,small in volume ,Malena present associated with epigastric pain 

SOB grade 4 since morning . No chest pain ,palpitations ,giddiness ,sweating 

No h/o fever ,cold,cough,burning micturition 

Personal history - 

appetite- lost 

Diet -veg 

 alcohol intake last 1 month back 

PHYSICAL EXAMINATION - 

No pallor /icterus/cyanosis/clubbing /oedema /lymphadenopathy 

Dehydration - present 

Temperature - afebrile 

PR - 112 bpm /min 

RR - 32 cpm 

BP - 90/50 

Spo2 room air - 88 

Grbs - 137mg /dl 

 SYSTEMIC EXAMINATION 

CVS - S1,S2 heard 

Respiratory - no dyspnea ,decreased breath sounds ,

ABDOMEN - 

Shape of abdomen - distended(fluid thrill ) 

Tenderness -no 

Hernial orifices -normal 

Free fluid - yes ,fluid thrill present 

Genitals - scrotal swelling positive 

CNS - Level of consciousness - drowsy 

Speech - normal ( at the time of admission) 

Glasgow Coma scale - E4V3M3

He came to casualty before with complaints of b/l pedal oedema and abdominal distension 

INVESTIGATIONS 

Rapid test for covid negative

ECG 

CHEST X RAY AP VIEW 

ABG

RFT

LFT 

Around 6 pm patient had bouts of vomitings followed by sudden cardiac arrest with absent central and peripheral pulses with falling saturations 

Positive cycles of cpr done ,received intubated with ET -7mm ,pre and post intubation secretions are aspirations ,active bleed + about 50 ml 

Post intubation vitals are 

Bp -100(sbp)

PR-98 bpm 

Spo2-94 % at room air 

Temperature - afebrile 

Post intubation pt was started on inotropes and connected to mechanical ventilation  

CVS - s1,s2 heard 

R/s - b/l crepts in IAA,IMA,ISA 

P/A - distended ,visible veins ,fluid thrills positive

PROVISIONAL DIAGNOSIS - CHRONIC LIVER DISEASE WITH OESOPHAGEAL VARICES 

Treatment given - BEFORE INTUBATION 

1)Head end elevation 

2)O 2 inhalation to maintain spo2 > 94

3)TAB LASIX 40 MG PO/BD 

4)TAB ALDACTONE 50 MG PO/OD 

5)TAB.PROPANOLOL 20MG PO/OD 

6)INJ.PANTOP 40 MG IV/BD 

7)INJ ZOFER 4 MG IV/SOS 

8)MONITOR VITALS - 4 TH HRLY 

9)GRBS - 6 TH HRLY 

10)I/O ,WEIGHT,ABDOMINAL GIRTH -CHARTING 

AFTER INTUBATION 

1)head end elevation 

2)RT feeds 50 ml 2 no hourly (water),100ml 4 TH hourly (milk protein powder )

3)INJ PANTOP 40 MG IV/BD

4)INJ ZOFER 4 MG IV/BD 

5)INJ NORAD 2 AMP IN 48 ML NS @16ML/HR (TO MAINTAIN MAP 55 TO 60 %)

6)INJ DOBUTAMINE 1 AMP IN 45 ML NS @ 3.5ML/HR

7)INJ TRANEXA IV stat 

8)INJ LASIX INFUSION @5MG/HR 

9)MECHANICAL VENTILATOR 

10)I/O ,TEMP CHARTING 

11)Monitor vitals 4 hourly 

Death summary

48-year-old male came to casualty with vomitings,loose stools and shortness of breath ,on presentation patient drowsy but arousable with spo2 88 at RA with hypotension 

patient was put on oxygen mask with supportive care. At around 4:30 PM on

 6/12 /2021 had sudden onset of profuse vomiting with sudden cardiac arrest, CPR done six cycles and intubated with ET -7mm and connected to mechanical ventilator ( ACMV-VC)

In view of hypotension,patient was started on ionotropes and monitored vitals and serial abg were done .even on ionotropes ,patient BP could not be improved, had cardiac arrest at 5 25 am on 7/12/21 with absent central and peripheral pulses with dilated pupils .CPR initiated and continued for 6 cycles .in spite of all the efforts,patient could not be revived and declared dead on 7/12/21 at 5 53 am with ecg showing no electrical activity 

Immediate cause :refractory hypotension and refractory metabolic acidosis (Post -cpr status )

Antecedent cause :chronic liver disease with grade 3 oesophageal varices with right heart failure