2. A 50 years old female presented to ER at 9 PM on
1) Obstipation and abdominal distension for 4 days
2) Multiple episodes of vomiting for 1 day
3. PAST HISTORY:
Patient is known case of metastatic signet cell
adenocarcinoma of sigmoid colon, received 3 cycles of
chemotherapy (CAPEOX regimen) and was planned for 4th
cycle of chemotherapy on 08/07/2021.
Patient received 3rd cycle of chemotherapy on 16/06/2021.
Patient had a history of similar complaints 3 days back, in
case of which patient was advised admission for further
management, but had got discharged against medical
advice citing personal reasons.
No other known comorbidities.
BP:110/60 mm of Hg
Spo2 : 98% ON ROOM AIR
Temp – 98.6 F
VITALS AT PRESENTATION:
7. Metastatic signet cell adenocarcinoma of the
sigmoid colon in sub acute intestinal obstruction.
Conservative management with IV fluids, NG insertion
8. Course in hospital:
DAY 1 OF ADMISSION:
• Medical oncologist opinion was sought on 01/07/2021 and on
discussion with surgical consultant decision to do CECT abdomen
and pelvis after ascitic tapping was taken to look for tumor burden
after 3 cycles of chemotherapy and also to rule complete luminal
obstruction of sigmoid colon.
• Under strict aseptic precautions and by using USG guidance 2
liters of straw colored ascitic fluid was drained.
• Patient was shifted to CECT abdomen and pelvis, but due to
absence of 18G IV cannula patient was shifted back to ward.
9. • In view of past chemotherapy peripheral vein cannulation
was difficult and for injection of IV contrast during CT scan
required a 18G cannula, hence EJV access was tried.
• During which patient had abnormal moments and became
unresponsive following which code blue was called.
• At 4:30PM patient vitals:
BP – Not recordable, Pulse – absent, GCS – 3/15.
10. • After 8 cycles of CPR patient was revived, and during
intubation it was observed that their was fresh blood pooled in
oral cavity( approximately – 200ml) and hence MTP was
called and 1 unit of PRBC and 2 units of RDP was transfused.
•Patient developed VT hence cardioverted with 200J and was
started on Inj Amiodarone.
• After counselling the family patient was shifted to HICU.
• Vitals at the time of shifting the patient to HICU:
BP – Not recordable, Pulse – 144/min
11. • In HICU arterial and central line was secured and was
started on inotropic supports which was gradually increased to
triple inotropic support.
12. DIFFERENTIAL DIAGNOSIS
- Erosive gastritis
- Oesophageal varices
Patient admitted to HDU @ 5:30 PM
Kept NPO , Continued on IV Fluids NS 100 ml / hour
and started on Omeprazole infusion .
13. In HDU
In HDU patient seen by ward on call at 5:45 PM
From 5:30 pm – 11:30 PM
- Vitally stable
- Symptomatically better
- GCS – 15/15
@11:30 PM resident was informed that patient had increased work of
Patient seen by resident at 11:40 PM and found to have decreased
response ( GCS – E2V1M3 ) 7/15
BP – 150/90 mm Hg , PR – 64/min , RR – 18/min
Shifted to ICU
14. In ICU
Received in ICU @ 12:00 AM
GCS – 6/15
Pupils – equal and reacting
BP – 140/70 , PR – 76/min , RR – 19/min , SPO2 – 89% in room air .
Intubated @ 12:30 AM ( midaz , fentanyl , scoline )
Comtiued on same treartment .
I/v/o sudden drop in GCS CT Brain was done @ 2:00 AM
CT report ( Critical alert ) informed to “Dr KYNSHEW “ at 3:20 AM
IVH in 3rd and 4th ventrincel , aqueduct and loccipital horns and lateral
ventricle with moderate hydrocephalus .
15. @ 8 :00 AM
BP – 80/40 mm Hg , PR – 46/min , GCS – 2T/10T
Started on ionotropes at 9:00 AM
@ 10:00 AM
BP - not recordable on ionotropes
Patient was started on antiedema measures
Neurosurgery consult was sought and case seen by surgery resident and
advised SURGICAL DECOMPRESSION
S/b Neurosurgeon @ 11:00 AM and advised surgical decompression
Patient attenders opted palliative care ( no consent for palliative care ).
Cardiac arrest @ 2:07 PM – death declared .
16. WHAT COULD HAVE BEEN AVOIDED –
Delay in protecting airway after sudden drop in GCS ( patient shifted to ICU
and intubated there )
Delay in shifting patient for CT Brain after drop in GCS ( 2hrs )
Error in communicating critical report
Delay in following up of CT report
Delay in initiating antiedema measures