I was doing my rounds in the ward and got a phone call from my ortho colleague K - urgent call to the ICU...
The nurse was preparing O2 for the patient at the bedside. I positioned myself to the bed top and started to bagged her. I spot the oximetry reading was 80% when I reached the bedside. I knew the case - the nurse in the ward had called me last night - the family was complaining in a bad manner about a bruise over rt forearm....
The patient is a 70 y/o female who sufferred from a femur fracture and undergone surgery few days ago. She had also suffered from some brain tumor and undergone surgery few years back. Both her son were drunkard and a lady was hired to care for her in the ward. The son would come to the ward on and off under the influence of alcohol questioning the nurses this and that. Most of the time, the sons would calm down after explaination by doctors. The bruise was noted after removal of a venocath. I explained to the son and calmed him down. The patient had c/o abd pain and I attended to that. A frank epigastric pain with normal EKG. She was troubleb by such problem since post ops. A small dose of pethidine would make her sleep all the day and some respiratory depression was noted. So NSAID was given instead but after couple of shot she had this epigastric pain and peptic ulcer was impressed.
I gave her a low dose of pethidine and some cimetidine.... no more calls about her that night...
And now, she was laying in front of me waiting for her intubation... K told me that she look drowsy and gasping for air was noted in the morning so he rushed her to the ICU stat.... She was confused and not fully comatose. She was biting and took me some strengthed to open her mouth. I managed to intubate her in 1 trial and sedated her with some propofol...
The SpO2 was quickily elevated to 100% after a few bagging... that ruled out pulmomary embolism but the heart rate worried me... it was 180-200/min on the monitor since I lay my eyes on it... the BP had crushed to 60/40mmHg after the intubation. I double checked the tube and the patient and nothing suspicious. By the time the hospital director and cardiologist was beside the patient. I proceeded with a internal jugular CVP and the reading was 12cmH20 - her skin turgor was poor though...
An EKG 12L was done and ischemia was noted. The rhythm was atrial fibrillation with rapid ventricular response. I decided to shock her as the BP was still lowish even after dopamine use. The cardiologist concurred with my decision and proceeded with the cardioversion starting with 30J(biphasic,sync). No response after the 1st shock and the current was increased to 50J (she was obese...). The 2nd shock resulted in asystole and chest compression was commenced.This was the 1st time I had an asystole after a sync cardioversion.... We managed to kicked back the heart within 1 mins and we got a call from the lab.... the sugar was 34mg% only.... what the @#$%^^&&***,(it had been 30min since I started to managed her...) I mummbled while ordering 4amp of 50% of GW..... she regained conscious after the sugar injection but her vital sign did not stabilized. She started to have fever and we had started her on dobutamine and steroid... Now, multifactorial leading to her failure... When I probed back to the history ... a sugar check was done in earlier that day in the morning which revealed 69mg% : the lady caring her had offered to feed her but she had only eaten some and vomited moments later - this event was not reported to the doctor nor managed further after the vomiting.... one of the crucial point. No proper passoever about the sugar reading was done during the passover to the ICU nurse....her hypoglycemia maybe due to poor feeding and finally worsen by sepsis....
She was still there this morning during my rounds - we treated her as septic shock with EGDT regimen. Her BP was ok and now the urine ... only 300cc for the past 22hrs...
Lesson of the day - sugar check !!!!!!!
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