Its 3am and youve been called to see

1
Its 3am and youve been called to see

• Cameron Platell

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I wanna go home?
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Nursing Staff

• Patient wants to leave.
• Seems agitated.
• Unable to do observations.
• Told wife to F Off that evening.

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52 year old male.

• Fell out of tree 5 days ago.
• 4 Fractured ribs on right side.
• Normal head / abdominal CT scan.
• No previous medical problems.
• Mild alcohol intake.

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Management.

• Admitted for analgesia
• Observation.
• Chest physiotherapy
• Intra-pleural marcain infusion.
• Pethidine / Maxalon

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First Contact

• Walking around 4 bed room.
• Other patients very annoyed.
• Aggressive.
• Making plausible argument to go.
• Pulls out intra-pleural infusion.

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COLLAPSES
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Assessment

• Airway and Breathing OK.
• Responding to pain only.
• Saturation 89.
• HR 154.
• BP 80/50.
• Temperature 35.6 oC

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Manage

• Oxygen.
• IV line (16g) - bloods FBP, UE, G H.
• Fluids - Normal saline 1 litre stat.
• Urinary Catheter.
• Chest Xray.
• ABG.

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Call for Help!

• Registrar
• ICU Staff
• Residents

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Progress

• HR 140, BP 85/60 after 1 litre.
• Saturation 92 on 8 l/min O2.
• Remains unconscious.

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Results

• FBP - Hb 173 g/l, WCC 37 109/l.
• UE - K 6.9, Ur 18.9, Cr 352 (mmol/l).
• ABG - O2 69, CO2 32, BE - 8.6.
• CXR - opaque right side.

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Management.

• Continue volume replacement.
• Needs central venous line.
• Needs ventilation.
• Given insulin/dextrose for K.
• Take blood cultures

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Conclusion

• Staph. Aureas infection of pleural space.
• Uncontrolled septicaemia.
• Multi-organ failure.
• Empyema of right chest.
• Decortication of right chest.

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Deceased

• After 15 days in ICU

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Its 1100 PM

• Patient with BP 210/90

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71 yr Female.

• Right Hemi-colectomy 5/7 (Ca).
• Just discharged from ICU.
• PHx
• Obesity
• Asthma
• Hypertension
• Peripheral Vascular Disease

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Assessment

• Obese and anxious.
• CVL and IDC.
• Nil orally, on TPN.
• Distended abdomen.
• Bowels open that morning.

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0100 AM

• Abdominal Pain.
• Afebrile.
• Normal HR BP RR Sat.

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200 AM

• Ongoing Pain.
• Dyspnoea.
• RR 28
• Sats 92
• HR BP UO normal.
• FBP WCC 2.2, UE normal.

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300 AM

• Ongoing Pain.
• Dyspnoea worse
• RR 32
• Sats 92 on 10l oxygen.
• UO 10mls last hour
• HR 119 BP 110/70

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400 AM

• CT Scan
• Wedge infarct right kidney.
• Grossly dilated gallbladder and bileducts.
• Small amount free fluid, no leak.

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600 AM

• Respiratory failure.
• RR 40 Sats 82 on 10l oxygen.
• Cardiac failure.
• HR120 BP 90/40
• Renal failure.
• UO nil Creatinine 130
• Metabolic failure.

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700AM

• Transfer to ICU.
• Noradrenalin infusion.
• Intubated and ventilated.
• Dialysis.

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1800

• Re-Operation
• Ischaemic small and large intestine.
• Anastomotic leak.

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Outcome

• Infarcted both legs post-op.
• Died of multi-organ failure within 48 hours.