Age: 55.0
Sex: M
Vaccine: COVID19, COVID19
Symptoms: Hypoperfusion, Hypotension, Immature granulocyte count increased, Influenza virus test negative, Intestinal ischaemia
Clinical narrative: 2/2/2021- seen in Ed with c/o intermittent fever following 2nd dose.  Redness to bilateral upper extremities, c/o some pain with urination, weak.  V/S stable, afebrile in ED.  Assess for infection.   No significant abnormal labs (see below), hydrated and discharged.   2/4/2021-  arrived in ED with c/o vomiting, seen earlier by PCP that day labs drawn.  Shortly after arriving in the ED copious amouts of emesis noted, the patient went into full cardiac arrest and CPR was started.   -Please see HPI above, in addition after intubation the patient coded again.  More epinephrine and lidocaine were given.  CPR was resumed.  We did obtain ROSC and targeted temperature management was pursued.  He is placed on a lidocaine drip and a right femoral central line was placed by myself.  At this time, norepinephrine drip was initiated given his continued hypotension.  Post intubation chest x-ray suggests possible abdominal pathology and once the patient was stabilized further, he was sent to the CT scanner where CT head without IV contrast and CT chest, abdomen and pelvis with IV contrast was obtained.  He did lose pulses once in the radiology suite.  This was brief.  IV fluids were initiated and he received over 2 L of crystalloid therapy.  He continued to be hypotensive in the emergency department and vasopressin was added.  He also had a single dose of Neo-Synephrine and IV push fashion to help bring his blood pressure up.  CT scan reveals probable bilateral aspiration pneumonia/pneumonitis and dilated loops of small bowel without a transition point and pneumatosis involving loops in the left upper quadrant.  I did try to initiate consult with critical care and possible transfer, however he continued to be unstable and coded requiring CPR multiple times.  He was given IV bicarbonate given his prolonged CPR state and pH.  Ultimately, the family decided to make the patient comfort measures only given his critical illness.  Shortly after making this decision he did pass away in the emergency department.  RADIOLOGY DIAGNOSTIC - CHEST PORTABLE 02/04 2051 *** Report Impression - Status: SIGNED  Entered: 02/04/2021 2059 IMPRESSION: 1. Findings highly suspicious for portal venous gas which can be seen in the setting of bowel ischemia.  Consider CT for further evaluation and/or surgical consultation. 2. Endotracheal tube 3.7 cm above the carina. 3. Low lung volumes with mild patchy perihilar opacities.   Final Report Signed by: M.D.,  Sign Date/Time: 02/04/2021 8:55 PM Impression By: MD CT SCAN - CT HEAD WO 02/04 2140 *** Report Impression - Status: SIGNED  Entered: 02/04/2021 2200 IMPRESSION: Negative for acute intracranial process.  No evidence of mass effect, acute hemorrhage or definite acute cortical infarct.   Final Report Signed by: M.D., Sign Date/Time: 02/04/2021 9:57 PM Impression By: - MD CT SCAN - CT CHEST/ABD/PELVIS W 02/04 2140 *** Report Impression - Status: SIGNED  Entered: 02/04/2021 2214 IMPRESSION: 1. Ill-defined patchy opacities within the bilateral upper lobes, right middle lobe, in consolidative opacities within bilateral lower lobes which could represent aspiration, and/or multifocal pneumonia. 2. Small right trace left pleural effusions. 3. Diffusely dilated small bowel without a transition point and mucosal hyperenhancement involving the colon with areas of pneumatosis involving loops of small bowel within the left upper quadrant and portal venous air consistent with hypoperfusion complex. There is a small caliber appearance of the aorta and a flattened appearance of the IVC is well. 4. Intravascular air within the IVC and bilateral iliac veins could be secondary to right femoral central lying injection. 5. Somewhat abnormal enhancement pattern of the kidneys with hypoenhancement of the medullary pyramids which may suggest hypoperfusion injury as well. 6. Probable nondisplaced rib fractures on the right at ribs 2 through