Primary survey
A
Airway was not patent and protected
Then oropharyngeal airway was inserted and intubated with ET Tube size of 7 for airway protection. procedure of intubation, prior to intubation any details?
B
Pre intubation
RR= 50 There was deep and labored breathing
SpO2 = 95% with 15 L/min of 100% oxygen with face mask
Post intubation
He was put on Mechanical ventilation with AC-VCV mode and the set parameters are
RR= 24 TV= 300-400 FiO2=100% PEEP=5
There was transmitted sound bilaterally
C
BP= 120/80 PR= 130-150
IV line was inserted bilaterally and he was resuscitated with 2 liters of NS.
D-
GCS 3/15 E-1 M-1 V-1
Pupil were dilated & fixed bilaterally. There was no motor preference
RBS= 200
E
Clothes were removed
To= 40.8oc and he was given paracetamol 1gm PO then temperature became 37.7oc. Inferior vena-cava was initially collapsed and full after fluid resuscitation. There was good cardiac contractility.
No pleural, pericardial and peritoneal collection
Secondary survey
This is a male patient on his 20’s presented to our ED after he ingested unspecified amount of 2,4-D herbicide unintentionally & lost his consciousness for about 16 hours’ duration. Associated with this he was having frequent vomiting of ingested matter of unspecified amount. His family noticed his mental status while they try to wake him up early in the morning.
Otherwise, there was no history of-
- suicidal attempt
- Chest pain, cough, contact with chronic cougher
- Bizarre behavior
- Abnormal body movement
- Incontinence
- Excessive salivation
- Previous history of intoxication
- Chronic medical illness
- Irritation of the eyes and skin
For this he was investigated with CBC, Coagulation profile, serum electrolyte, Organ function test, ECG
On CBC
Hg- 13.8 Hct= 41.6
WBC= 9100 with neutrophil count of 86.9% and lymphocyte of 10%.
Platelet= 242K
On electrolyte
Na+=154 K+=3.66 Cl-=1.62
Liver function test
GPT= 62.4 GOT= 157.7
Coagulation Profile
PT= 17.3 INR= 1.35
Table 1. Pre-intubation Vital signs of the patient
Date
|
Aug 17,2022
|
Aug 17,2022
|
Aug 17,2022
|
Time
|
18:30
|
19:00
|
19:30
|
BP
|
123/54
|
128/61
|
112/61
|
PR
|
152
|
154
|
164
|
RR
|
15
|
48
|
35
|
T0
|
40.8
|
37oC
|
41.2oC
|
SPO2
|
96%
|
93%
|
98%
|
O2 Lit
|
10L
|
15L
|
10L
|
RBS
|
200mg/dl
|
|
|
For this he was managed with first with resuscitation with 2 bags of NS. He was given Paracetamol 1gm PO QID. He was given Lasix 20 mg IV stat and diazepam 10 mg IV stat.
Then he was intubated with 7 mm size of ET tube and was on ketofol (ketamine & propofol with 1:1 ratio) drip started with 5mcg/kg/min on escalated base.
He was also being given sodium bicarbonate 150Meq in 400 ml of NS.
He was also on adrenalin and noradrenalin drip with escalation up to the dose of 2mcg/kg/min and 1.5mcg/ kg/min, respectively.
![](https://myfiles.space/user_files/58854_b38fc7f3db2c487f/58854_custom_files/img1682469013.png)
He was also given ceftriaxone 1gm IV BID and metronidazole 500 mg IV TID. He was on strict
vital sign follow up. His urine output follows up showed -500ml fluid balance.
His BP was still dropping and his pulse become weaker despite high vasopressor offered. CPR was differed due to poor outcome of the patient.
The patient passed away after 7 hours of ED stay with the Possible immediate cause of death was multiple organ failure secondary to refractory distributive shock 2o to 2,4-D poisoning.