Whiting, Edith
Deceased
Edith Whiting
Demographics
68y, female
Date of death
2005-08-13
Finding date
2010-06-11
Cause of death
Anaphylactoid reaction to intravenous CT scan contrast medium leading to cardiorespiratory arrest
AI-generated summary
A 68-year-old woman with asthma presented to hospital with abdominal pain suggestive of biliary obstruction. A CT scan with intravenous contrast was ordered to clarify the diagnosis before potential surgical transfer. She had asthma exacerbations requiring medication twice on the day of the scan, though documentation of the second episode was disputed. The contrast injection triggered a severe anaphylactoid reaction with bronchospasm and cardiorespiratory arrest. Resuscitation was suboptimal: adrenaline administration was delayed when it should have been given immediately as the mainstay of anaphylaxis treatment; intubation required multiple attempts; and fluid resuscitation was inadequate. The coroner found the decision to use contrast was not unreasonable given the clinical context, but the resuscitation response lacked coordination and appreciation of anaphylaxis management principles. Better early adrenaline administration and increased fluids might have improved survival chances, though recovery remained unlikely given the severity of the reaction.
AI-generated summary and tagging — may contain inaccuracies; refer to original finding for legal purposes.
Error types
Drugs involved
Clinical conditions
Contributing factors
- Delayed administration of adrenaline in anaphylaxis
- Inadequate intravenous fluid resuscitation
- Lack of coordination and leadership during resuscitation
- Multiple intubation attempts due to airway swelling
- Uncertainty regarding proper endotracheal tube placement
- Absence of capnography monitoring devices
- Incomplete documentation and communication regarding asthma exacerbations on day of procedure
Coroner's recommendations
- Standardise the stocking of emergency trolleys
- Include CO2 (capnography) detectors/monitors in emergency trolleys
- Ensure a senior doctor is available on hand whenever intravenous contrast is administered
- Implement training changes for staff in anaphylaxis management and resuscitation procedures
- Ensure clear leadership structure during emergency resuscitation events
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