Case of a 75 year old lady brought in an unresponsive state

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Neha Tipparaju

Roll no. 100

Case of a 75 year old lady brought in an unresponsive state

My case is of a 75 year old lady, a homemaker in Miryalguda, who was brought to casuality in an unresponsive state with no recordable blood pressure and no pulse. SPO2 35% on 15 liters of O2.

CPR was started according to 2020 American Heart Association guidelines.

Patient was intubated with 7.5 cm Endotracheal Tube and bilateral air entry checked cycles of CPR were done with 1 milligram adrenaline after each cycle

Return of Spontaneous Circulation was obtained after 6 cycles.

Timeline of events and History of Presenting Illness:

Patient lived a normal life, taking turns residing with her 4 sons.

20 years back, Patient had an episode of chest pain and palpitations. She was taken to a private hospital and diagnosed to have Myocardial Infarction due to coronary occlusion and a Percutaneous Coronary Angioplasty was done with a stent placed. She was also diagnosed with Diabetes Mellitus, Hypertension and Obstructive Sleep Apnea. She has been on regular medication since then.

In 2017, she suddenly developed shortness of breath, drowsiness and pedal edema. She was diagnosed to have Type 2 respiratory failure due to her OSA.

In the private hospital,

2D echo showed : mild concentric LVH, normal LV function and Grade 3 diastolic dysfunction.

CT pulmonary angiography showed Pleural effusion and Ground glass opacities.

Sleep studies were done and the patient was advised BiPAP which she used every night.

Since then, she has been taking her medication regularly and also monitoring her weight, blood sugar levels and her blood pressure.

Atorvastatin + Clopidogrel

Metformin

In December, 2021 she had recurrent episodes of shortness of breathlessness, early in the morning which was sudden in onset, relieved on lying down, occuring every 10 days. She was taken to a local hospital during one of these episodes and was advised nebulization of the following drugs when the attack repeats:

1 month back, The patient stopped using BiPAP due to technical difficulty and since then she was said to have excessive daytime sleepiness.

On the morning of 29/3/2022, Patient awoke from sleep and was continuing her activities when she suddenly developed shortness of breath of Grade 4. She was given nebulization at home but did not improve and so taken to a local doctor who found her blood pressure to be 230/110 mmHg. He administered an injection of Labetalol. The patient was on her way to Hyderabad in an ambulance when she became unresponsive and went into cardiac arrest. She was then brought to our hospital where she was resusitated.

Post CPR vitals:

Afebrile

BP 170/100

PR 110 BPM

CVS S1,S2 +

RS BAE+, Decreased air entry in Lt mammary area

Patient has not regained consciousness. She has episodes of seizures where she had eye opening and clonic movements.

Personal history:

The patient is a pure vegetarian. Her appetite, before the event was normal and bowel and bladder were regular. She had excessive daytime sleepiness. No allergies and addictions.

Family history: Not significant

General Examination:

Patient is examined in a well lit room, in supine position. She is not conscious and is seen to be on ventilatory support. Sedated and paralysed.

On examination no signs like pallor, icterus, cyanosis, clubbing or generalized lymphadenopathy were observed. Pedal edema with discolouration of feet is seen.