Alcohol Induced Pancreatitis with a Fatal Complication

Expectation from this E log :

 This is online E log book to discuss our patient's de-identified health data shared after taking signed informed consent. Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence based inputs .This e-log book also reflects my patient centered  online learning portfolio and your valuable comments on comment box is welcome.

About the patient :

The patient is a 32 year old man hailing from the southern part of India , who is a Lorry driver by occupation presented to the casualty on 25/May/2021 with complaints of

Pain Abdomen since 3 days which has become extreme with passing time

constipation since 3 days

Vomiting Episodes since 2 Days

Shortness of Breath since 1 day

Elaborating on his Chief Complaints :

The Patient is a heavy alcoholic for the past 15 years, he was apparently fine 5 years ago when he had an attack of Acute Pancreatitis , from which he recovered with treatment .

He did not bring any changes to his Alcohol intake ;

began experiencing Abdominal Pain since the past 3 days

Pain is in the upper abdomen (Epigastric Pain) , dull in nature , radiating to the back 

Vomiting Episodes have been 2-3 times a day for the past 2 days, contents of Vomitus is Food.

Shortness of Breath is of Grade 1 ; since the past day.

Past History :

The patient has a history of pacreatitis 5 years ago.

Not a known case of DM , HTN .

Has not had TB, Epilepsy , Asthma 

Personal History :

He has Normal Appetite ,

takes mixed Diet

His Bowel and Bladder movements are normal and regular ( but patient complains of having constipation since the past 3 days )

no known Allergies.

 

Hand Written Notes on History :

ADDICTION DETAILS :

The patient uses chewable Tobacco.

He is an alcoholic for the last 15 years.

Consumes 5-6 full bottles of alcohol in a week.

volume of intake :  ( 750 * 6 ) ml

Initial Assessment Notes: 

FINDINGS OF THE PATIENT ON PRESENTATION 

Vitals :

Pulse : 

Rate : 130 bpm

Rythm : regular

Volume : Adequate

Condition of Vessel : Normal

Delays : absent.

Blood Pressure :

Value : 130/90 mm Hg recorded on the Right Arm ( Brachial Artery )

Postion : Supine

Respiratory Rate:

24 cps

Spo2 : 97 % on room air

Pain : Present

( 8 on Wong Baker Faces Pain scale )

GENERAL EXAMINATION  :

Mild Dehydration

Systemic Examination :

Abdomen : Tenderness and rigidity in the epigastric and hypochondriac region ;Sluggish Bowel Sounds.

SIGNS:  Cullen's Sign ; Fox's Sign , Grey turner 's Sign were negative.

REPORTS SHOWN  AT THE TIME OF PRESENTATION :

CECT :

Pancreatitis

Mild Ascites

B/L Mild pleural Effusion

with Consolidative lesions in B/l lower lung lobes.

CTS :8/10

USG : Grade 1 Fatty Liver ; Pancreatitis

Blood Works :

Hb : 14.6

TLC : 17500

Platelet : 2.32

Serum Amylase :271

Serum Lipase :137

Chest X Ray @ time of Admission

ECG @ time of Admission

INTERVENTIONS DONE IMMEDIATELY AFTER THE PATIENT PRESENTED :

Analgesia

Fluid Rescusitation

Ultrasonogram Findings ( done after admission ) :

• Body of Pancreas Edematous with Altered Echotexture 
•  Peripancreatic Fluid Accumuation seen

• Mild Ascites
• B/L Pleural Effusion
• Grade 1 Fatty Liver

2D Echo :

OTHER CRISIS  EVENTS WHICH FOLLOWED IN THE PATIENT : 

TIMELINE :

25/May /2021  12:30 pm :

Patient began having Tachycardia , Tachypneoa , with Hypoxia.

Diagnosed with Supraventricular Tachycardia.

Refractory to Vagal Manouvres 

Refractory to Adenosine

Patient was electively intubated in view of ARDS and administered Amiodarone.

Plain Chest Radiograph : Post Intubation

25/May/2021   6:30 pm :

Patient developed Hypotension

Ionotropic support given.

Amiodarone infusion continued in lieu of Arrythmia .

D Dimers levels elevated .

Anticoagulation started .

26/May/2021  1:00 am :

Patient suddenly developed Bradycardia with fall in Oxygen Saturation ( 48 % )

Central Pulses not felt

CPR done in accordance with ACLS guidelines inspite of which he could not be rescusitated ,

Declared dead at 1:53 am.

ECG @ 26/May/2021 1:53 am

ECG STRIPS : 

25/May/21  1:30 pm

25 May 2021 2:37 pm

 25/May/21  2:38 pm

25/May/2021 

7:00 pm

no electical activity

26/May/2021

1:53 am

OUTCOME : 

 Immediate Cause of Death : Pulmonary Embolism

Antecent Cause of Death : Severe Acute Pancreatitis ; ARDS

Corelation Of Pulmonary Embolism in Patients of Pancreatitis :

DISSEMINATED INTRAVASCULAR COAGULOPATHY 

What Could Have Been Found on Autopsy :

• Discussion :

Why were the signs ( indicating Coagulopathy ) absent in the patient who developed a massive coagulopathic crisis later ?  

What could have been done pro actively to forsee the DIC ?

What could have been the appropriate Ventilator Settings used in this patient ?