Death Audit Mr Rasika Champia 40/ Male.

Dr Smarajit PatnaikConsultant Orthopaedic

Apollo Hospitals, Bhubaneswar.

12.10.14

• Received in ER with alleged history of RTA .• 24 hours since injury. • Initial evaluation• Polytrauma – Crush injury to left leg, and right

thigh, abdominal pain and distension, decrease urination

• Vitals : BP 60/40, HR 120, RR 20, Airway patent, Breathing normal. Hb 5.1

Left leg

• Degloving injury• Underlying bone and muscles exposed.• Distal pulses and sensation preserved.• Fractures: Alae of sacrum and both superior

and inferior pubic rami. No vertical shearing or instability. Comminuted peritrochanteric fracture. Compound Grade III(B) fracture left leg.

Initial evaluation and treatment

• Admission in ICU• PRC 1 unit transfusion• Foleys catheterization• Antibiotics Piperacillin and tazobactum and

linezolid and metrogyl.• Debridement of open wound and splinting in

ER.• Opinions sought : Genaral surgeon, Plastic

surgeon, Nephrologist. Cardiologist.

Nephrological evaluation

• Hypovolumic shock• AKI• Rhabdomyolysis.• DIC.• CLD.

Surgical evaluation

• CT evalution Mild to moderate peritoneal collection and mid small bowel focal wall injury.

13.10.14

• Planned for debridement of wound on leg and external fixator immobilization and exploratory laparotomy.

• In view of severe metabolic acidosis, and renal shut down discussed with nephrologist and planned for pre procedure dialysis.

14.10.14

• Surgical debridement and external fixator applied.

• Exploratory laparotomy Haemoperitoneum about 700 ml, mesenteric

tear with 4 cm of devitalezed ileum segment, multiple mesenteric haematoma. Lacerated wound over retroperitoneum exposing ccontused psoas muscle and ureter. Haematoma was extending upto c loop of duodenum.

15.10.14

• SLED• FFP 6 units and PRC 2

units.• Antimicrobials to

Imipenem, Clindamycin and Fluconazole.

• Hb 4.4• TLC 6.2

16.10.14

• SLED on• PRC 1 unit.• Dressings of leg wound

and surgical sites.• Poor prognosis, family

meeting.

• Hb 5.2, TLC 8.2• Platelet 42000• INR 3.26 -1.91.• Creatinine 3.3 – 2.9.• Urine 410 ml , UF 750

ml.

17.10.14

• Febrile 99.5. • Day 4 ventilator.• SLED continuing.• Platelet concentrate 2

units.• TPN started.• Abdomen soft, bowels not

passed.• Dressings of leg wound and

pin tracts daily.• Self extubated.

• Hb 6.4, Platlet 37000• Creat 3.4• INR 1.43• Lactate 2.2• UF 1000 ml, urine 350

ml.

18.10.14

• Obeying commands.• Vitals stable. • I/O 2049/1970.• TPN 40ml/hr. motion

passed.• Plan: SLED c/m

• Hb 7.8, TLC 6250.• Creat 3.4.

19.10.14

• SLED.• I/O 1056/325 last 24 hrs

and no urine passed untill 8.00 pm.

• Haemodialysis at 10.20 pm.

• Motion not passed.• Temp 101.2• Abdominal drains in situ

drain 290 ml.• Leg dressings done.

• Blood c/s no growth

20.10.14

• Overall well.• Repeat debridement

done in bed side.• Afebrile.• I/O 950/1960 • Sensorium detoriated

over night.

• Hb 7.7

21.10.14

• GCS at 4.00 am 3/15.• Shallow respiration• Intubated.• Haemodialysis by 6.00 am.• At 8.45am : Afebrile, I/O

1003/405.• Antibiotics :Tigicycline.• Poor prognosis, family

meeting.• At 7.45 pm : Clinically dead

after CPR following asystole.

• ABG ph6.87, Lactate 16.