1. Death Audit Mr Rasika Champia 40/ Male. Dr Smarajit Patnaik Consultant Orthopaedic Apollo Hospitals, Bhubaneswar.

2. 12.10.14 Received in ER with alleged history of RTA. 24 hours since injury. Initial evaluation Polytrauma – Crush injury to left leg, and right thigh, abdominal pain and distension, decrease urination Vitals : BP 60/40, HR 120, RR 20, Airway patent, Breathing normal. Hb 5.1

3. Left leg Degloving injury Underlying bone and muscles exposed. Distal pulses and sensation preserved. Fractures: Alae of sacrum and both superior and inferior pubic rami. No vertical shearing or instability. Comminuted peritrochanteric fracture. Compound Grade III(B) fracture left leg.

4. Initial evaluation and treatment Admission in ICU PRC 1 unit transfusion Foleys catheterization Antibiotics Piperacillin and tazobactum and linezolid and metrogyl. Debridement of open wound and splinting in ER. Opinions sought : Genaral surgeon, Plastic surgeon, Nephrologist. Cardiologist.

5. Nephrological evaluation Hypovolumic shock AKI Rhabdomyolysis. DIC. CLD.

6. Surgical evaluation CT evalution Mild to moderate peritoneal collection and mid small bowel focal wall injury.

7. 13.10.14 Planned for debridement of wound on leg and external fixator immobilization and exploratory laparotomy. In view of severe metabolic acidosis, and renal shut down discussed with nephrologist and planned for pre procedure dialysis.

8. 14.10.14 Surgical debridement and external fixator applied. Exploratory laparotomy Haemoperitoneum about 700 ml, mesenteric tear with 4 cm of devitalezed ileum segment, multiple mesenteric haematoma. Lacerated wound over retroperitoneum exposing ccontused psoas muscle and ureter. Haematoma was extending upto c loop of duodenum.

9. 15.10.14 SLED FFP 6 units and PRC 2 units. Antimicrobials to Imipenem, Clindamycin and Fluconazole. Hb 4.4 TLC 6.2

10. 16.10.14 SLED on PRC 1 unit. Dressings of leg wound and surgical sites. Poor prognosis, family meeting. Hb 5.2, TLC 8.2 Platelet 42000 INR 3.26 -1.91. Creatinine 3.3 – 2.9. Urine 410 ml, UF 750 ml.

11. 17.10.14 Febrile 99.5. Day 4 ventilator. SLED continuing. Platelet concentrate 2 units. TPN started. Abdomen soft, bowels not passed. Dressings of leg wound and pin tracts daily. Self extubated. Hb 6.4, Platlet 37000 Creat 3.4 INR 1.43 Lactate 2.2 UF 1000 ml, urine 350 ml.

12. 18.10.14 Obeying commands. Vitals stable. I/O 2049/1970. TPN 40ml/hr. motion passed. Plan: SLED c/m Hb 7.8, TLC 6250. Creat 3.4.

13. 19.10.14 SLED. I/O 1056/325 last 24 hrs and no urine passed untill 8.00 pm. Haemodialysis at 10.20 pm. Motion not passed. Temp 101.2 Abdominal drains in situ drain 290 ml. Leg dressings done. Blood c/s no growth

14. 20.10.14 Overall well. Repeat debridement done in bed side. Afebrile. I/O 950/1960 Sensorium detoriated over night. Hb 7.7

15. 21.10.14 GCS at 4.00 am 3/15. Shallow respiration Intubated. Haemodialysis by 6.00 am. At 8.45am : Afebrile, I/O 1003/405. Antibiotics :Tigicycline. Poor prognosis, family meeting. At 7.45 pm : Clinically dead after CPR following asystole. ABG ph6.87, Lactate 16.