NSR 6-1-23 OSNA + death caseeeeeeee.pptx

night shift report

1. NIGHT SHIFT REPORT Friday, January 6 th 20 23 Consultant on Duty : Dr. dr. Lina Lasminingrum , Sp.T . H . T .B. K . L Subsp. Oto (K) Chief on D uty : dr. Rano Doctor On Duty : dr. Amalia dr. Dara 1/9/23 1

2. Chief Complaint : Difficulty in breathing The patient came with difficulty in breathing that worsened 1-month prior to admission. Difficulty in breathing has been felt since approximately 6 months before. The complaint started with hoarseness 1 year ago after radiotherapy. Pain in swallowing +, sore throat +, hot potato voice (-). The patient can only eat soft food and drink. Complain of nasal congestion (-), double vision (-), nosebleed (-). The patient has been diagnosed with nasopharyngeal carcinoma in 2020, and patient has been done chemotherapy carboplatin-paclitaxel 3 times and radiotherapy 33 times 1 year ago. History of smoking (-), history of frequent consumption of salted fish +, use of mosquito coils (-). History of HT (-), DM (-). History of cough (-), fever (-), contact with Covid-19 patients (-). History of allergy (-). Due to her complaint, the patient came to Pagelaran Hospital, then referred to Hasan Sadikin General Hospital for further management. 1 . Female, 49 th years o ld , 22.00 pm

3. PHYSICAL EXAMINATION General state: Fully alert BP: 129/80 mmHg, RR : 28 x/m, HR : 84 bpm , no febrile, Sat O 2: 94% free air 98% on nasal canule 4 lpm Stridor inspiration +, expiration (-) , retraction suprasternal +, intercostal + , epigastrium (-) ORL-HNS examination : Both ears : external auditory canal not hyperemic +/+, discharge -/- , cerumen -/-, ear drum intact +/+, light reflex +/+, retro auricular not hyperemic +/+ Nasal cavity : mucosa not hyperemic +/+, inferior turbinate eutrophic +/+, deviation of septum (-), air passage +/+ NPOP : Tonsil T1-T1 not hyperemic, pharynx not hyperemic MF : symmetric, cranial nerve paralysis (-) Neck : Lymph nodes are not palpably enlarged Indirect Laryngoscope : plica vocalis dextra paralysis +, mass (-)

4. Laboratory Finding 06/01/2023 Hb 13.7 Hct 41.6 Leu 12.370 Erit 5.75 Tro 337.000 PT/APTT/INR 13.7/26.97/0.97 Na/K/Cl 139/4.4/101 pH 7.340 pCO2 47.5 pO2 172.8 HCO3 25.8 tCO2 27.3 BE 5.4 Sat 99% Rapid Antigen Sars Cov-2: Negative

5. Neck Soft Tissue X-Ray (06/01/23)

6. Chest X-Ray (Hasan Sadikin Hospital, 06/01/23)

7. WD/ Grade II Upper airway obstruction due to Suspicious vocal cord paralysis post radiotherapy DD/ tracheal stenosis C7-TH 1 + Nasopharyngeal carcinoma post chemotherapy and radiotherapy Management: • Observation of vital signs, shortness of breath • IVFD RL 1500 cc/24 hours • O2 saturation target oxygenation > 94% • Plan to perform tracheostomy per LA

8. Had been perfomed Tracheostomy /LA (RN/TK/GH/EX) DO : Found 3nd-4rd tracheal ring Bleeding : 5cc

9. WD/ Suspicious plica vocalis paralysis post radiotherapy DD/ tracheal stenosis C7-TH 1 + nasopharyngeal carcinoma post chemoradiation which has been performed Tracheostomy post operation day 0 Management: Observation of vital signs, subcutaneous emphysema, bleeding IVFD RL 1500cc/24 hours Suction and humidification as effective as possible Balloon deflated POD 2 Change stoma gauze/day Therapy: Cefixime 2x200 mg per oral Mefenamic acid 3x500 mg per oral Acetyl cysteine 3x200 mg per oral

10. Death Case

11. Girl, 2 months old (17.30) The patient was consulted from Pediatric Department with diagnosis of Bronchopulmonary Dysplasia + Pneumonia + Suspected Laryngeal Stenosis dd / Laryngomalacia + Anemia due to dd / Infection, Inflammation (repair) + Ventricular Septal Defect dd / Patent Ductus Arteriosus + Microcephaly. The patient complained of difficulty in breathing since birth and spontaneous breathing was inadequate, so he was intubated and put on a ventilator at Dustira Hospital. From the 1st day until 65th day of treatment, the patient was placed on a ventilator (NICU 30 days, PICU 35 days), with ETT No. 4.5 with a depth of 8.5cm. Complaints are not accompanied by wheezing, blueness around the mouth or the tips of the toes and hands are absent. Complaints are not accompanied by seizures or decreased consciousness. Because there was no improvement the patient was referred from the Dustira Hospital PICU to RSHS for further management. Patient's 2nd child from mother P2A0 was born SC with indications of oligohydramnios, preterm 35-36 weeks, born breathing and moaning, down score was 4 and increase to 6.

12. PHYSICAL EXAMINATION General States : under sedative , seriously ill PR : 110x/m T : 36,7 C RR : 42 x/m with ventilator O2 Sat : 100% S tridor inspiration + , expiration (-) suprasternal retraction (-), Intercostal (-), Epigastrium + T horax : Rh +/+ , Wh : +/+ Local state : Both ears: ear canals not hyperaemic +/+, discharge -/- , tympanic membrane +/+, light cone reflex +/+, RA not hyperaemic +/+ Right Nasal cavity: NGT is installed, others are difficult to assess Left Nasal cavity: mucous not hyperaemic +, inferior turbinate eutrophic +, septum deviation (-), air passage + NPOP : ETT is installed, connected to ventilator MF : symmetric, other difficult to evaluate Neck : lymph node enlargement (-)

13. Flexible Fiber Optic Laryngoscopy ( January 6 th 2023)

14. Thorax X-Ray ( January 6 th 2023)

15. WD/ laryngeal edema + laryngomalacia + Bronchopulmonary Dysplasia + Pneumonia + Suspected Laryngeal Stenosis dd/ Laryngomalacia + Anemia due to dd/ Infection, Inflammation (repair) + Ventricular Septal Defect dd/ Patent Ductus Arteriosus + Microcephaly. Management Observation of vital sign, breathing Plan to perform tracheostomy /LA

16. Pediatric Department Management Ventilator with ETT 4.5 8.5 cm deep, PC mode, FiO2 30%, PEEP 5, IPL 12, RR 30x/m, I:E 1:2 Fluid requirement for intubated children except TPN 4 ml/hour REE calorie needs 120 kcal/day tdd 8x50 cc of liquid food Midazolam 1 mcg/kg/minute Cotrimoxazole 12mg/8 hours PO (H-9) -> plan to stop, replace Cefotaxime 3x140 mg IV Bufacomb cream 3x1 ue Consult to ENT department

17. Time Observation Management 17.00 Tracheal cannula No. 4.5 was installed 18.00 Desaturation occurred, HR: 160x/minute R: 45x/minute SpO2 : 50% intubated with ETT No. 4,5 depth 11 cm 18.30 HR: 120x/minute R: 35x/minute S: 36.6°C SpO2 : 99% A tracheal cannula was installed no. 3,5 and 3 18.45 HR: 90x/minute R: 30x/minute S: 36.6°C SpO2 : 40% Re-intubated with ETT No 4.5 at a depth of 11 cm, VTP was performed 18.50 HR: 110x/minute R: 30x/minute with VTP S: 35°C SpO2 : 100% Re-intubate with ETT No 4 at a depth of 11 cm (because the ETT balloon does not inflate) 19.00 HR: 20x/minute R: 30x/minute with VTP S: 35°C SpO2 : 80% CPR and VTP were performed Bolus adrenaline 0.25ml flash NaCl 0.9% 10cc (1:10.000) 19.05 HR: 45x/minute R: 30x/minute with VTP S: 35°C SpO2 : - CPR and VTP continued 19.15 HR: - R: VTP S: 36,5°C SpO2 : 60% CPR and VTP continued 2nd adrenaline bolus 0.25ml flash NaCl 0.9% 10cc (1:10.000) 19.30 HR: - R: VTP S: 36,5°C SpO2 : 80% Family informed consent The patient was declared dead by the doctor on duty in front of his family

18. Cause Of Death: Cardiac arrest due to suspected vagal reflex + Respiratory failure ec suspected bronchopulmonary dysplasia + bronchopneumonia + aspiration

19. Thank You