A case of Unresolved Status Asthmaticus

A 29 year old, 80 kg male patient, known asthamatic since childhood on irreg medications, admitted to our hospital with cough, cold since 2 days, n breathlessness of 1 day duration. Patient nebulised, inf aminophylline, iv steroids given. No relief. Raised pCO2, low pO2-intubated n ventilated. Kept deeply sedated, paralysed.
Post ventilation intrinsic PEEP of 18cm H2O. pCO2 of 92mmHg. Low RR, low TV, high expiratory time ventilation. Tracheal secretions thick, purulent. Blood inv- TLC 15000. PCT<0.5. Treated with IV antibiotics (Imipenem, Linezolid, Claribid, Tamiflu) , infusion doxophylline, iv solumedrol, Nebulisation with salbutamol, Ipravent, Budecort; s/c Terbutaline.
48 hours later, persistent spasm, Intrinsic PEEP 11 cm H2O, pCO2=60 mmHg.
Please post your suggestions...

A case of Perforative Peritonitis with MCA infarct

A 37 year old male patient, admitted to our hospital, with 3 days history of abdominal pain, in severe shock...BP not recordable, Carotids present, HR=140/min. Resuscitated as per EGDT guidelines... Detected to have Perforation... Operated after optimization within 6 hours of admission. Intra-op hemodynamically maintained...found to have a Pre-pyloric perforation...repaired. Inv: TLC =18000/cmm, Platelets = 4 lacs/cmm, Creat= 2.6mg/dl, Coag normal, CXR=clear, CD Echo= normal.
Day2 - Improved hemodynamically, Ionotropes tapering, Urine output good, Creat decreased from 2.6 to 1.7 mg/dl. RS - Clear. Leucocyte count decreasing, Platelets decreased from 4 lacs to 2 lacs/cmm
CNS- Drowsy, momentarily opens eyes to pain, not following any commands, attempts to localise pain with right upper limb, Pupils bilaterally equal, reacting to light.
Same midnight, has repeated episodes of hypoglycemia ( least sugar level = 63mg/dl).
Day 3 - early morning - Right pupil dilated as compared to left. BP decreasing again, Increased ionotropic requirement, Platelets decreased to 70000/cmm. TLC=9000/cmm.
CT Brain plain done...showing a huge right MCA infarct, with midline shift n early herniation.
What could be the reason for the infarct???
Please post your comments.... N your experiences....

A Case of Anterior wall MI with Septal rupture.

A 56 year old man, no previous co-morbidities, is shifted to our tertiary care centre from a nursing home, where he was admitted the evening prior with chest pain of 2 hours duration, sweating and low BP = 80/45 mmHg. ECG demonstrated anterior ST elevation for which he was given aspirin, r-TPA, heparin. His symptoms resolve. Serum chemistries reveal a peak CPK of 1800 and a CK-MB fraction of 15%. He continues to be hypotensive, and his examination reveals a holosystolic murmur. 2D Echo shows a large VSD.
On arrival to our centre, he is conscious, oriented, appears mildly dyspnoeic and BP is recorded 60/35 and his pulse is 112 and regular.
We intubated and ventilated him. Put an Intra-aortic balloon pump, and started ionotropic support at moderate doses and could get the BP up to 72/40 mmHg.
Please give your suggestions. How do you manage this case?
Post your comments and suggestions in the comments below.