31 results for “blood gas analysis”
2y · Male·Perinatal asphyxia leading to cerebral anoxia and subsequent multi-organ failure
…old. Critical clinical lessons emerged regarding neonatal assessment: persistently pale newborns with cord blood pH 7.02 and hypothermia require investigation for anaemia and foetal-maternal haemorrhage, and repeat bloo…
66y · Female·retroperitoneal haemorrhage due to anticoagulation following right cerebrovascul…
… right carotid artery instead of the jugular vein. Critical failures included: non-recognition of arterial blood on blood gas analysis (5.02am, 17 June), radiologist's failure to identify malposition on chest X-ray, eig…
25y · Male·Multiple system failure and ingestion of sodium nitrite
…3pm. He deteriorated to cardiac arrest at 10:26pm. The critical delay in treatment occurred because venous blood gas results showing severely elevated methaemoglobin (70-86%) were not configured to display reference ran…
39y · Male·respiratory failure and cardiac arrest
…police noted concerning psychiatric behaviour. He was appropriately assessed in the Short Stay Unit, where blood gas analysis revealed critical hypoxemia (pO2 48mmHg, PaCO2 100mmHg) following midazolam administration. D…
57y · Female·Intra-abdominal Haemorrhage following Appendectomy, with contributing factor of …
… failures included: incomplete handover between anaesthetist and post-operative team; misinterpretation of blood gas analysis; failure to involve the surgeon when post-operative deterioration was apparent; and absence o…
1y · Female·sudden cardiac death on a background of rhinovirus infection
…s (respiratory rate >70, elevated heart rate) as requiring escalation despite fever; (3) the importance of blood gas sampling when vital signs deteriorate; (4) implementing Between the Flags vital sign monitoring system…
0y · Female·subgaleal haematoma complicating an obstructed labour
…SGH was not identified until 7.30am, approximately 6 hours after birth. Earlier recognition and aggressive blood pressure support may have prevented deterioration, though outcome was likely poor. Key lessons: always com…
70y · Female·Cardiac arrest caused by a combination of gastric haemorrhage and pneumonia exac…
Mrs Kathleen Anne Conlan, 70, died from cardiac arrest caused by gastric haemorrhage and pneumonia on a background of coronary artery disease. She presented with severe epigast…
54y · Female·complications related to post-polio syndrome and chronic respiratory weakness; n…
Gabriele Hannemann, a 54-year-old woman with severe post-polio quadriplegia and chronic respiratory failure, died suddenly at home during consensual sexual activity. She had severely compromised lung function (13% predic…
63y · Male·Right cerebral infarction caused by infusion of medication via central venous li…
…he arterial line, causing right cerebral infarction. The clinician relied on absence of pulsatile flow and blood colour to confirm placement but failed to perform manometry, transduction, or blood gas assessment despite…
43y · Female·Severe diffuse hypoxic brain injury caused by administration of supratherapeutic…
…lkalosis, and hypokalaemia. Brain swelling and death resulted. The consultant failed to adequately monitor blood gas results showing critical electrolyte derangements, did not consult available Toxicology Hotline until …
44y · Male·pneumonia (with multiple left-sided rib fractures as the antecedent cause)
…rate to cardiac arrest. Expert opinion suggested that appropriate aggressive resuscitation, fluid loading, blood cultures, broad-spectrum antibiotics, and ICU involvement within the first 60 minutes might have prevented…
Jessica: disseminated intravascular coagulation following haemorrhage (subgaleal…
…th deliveries were technically appropriate. Jessica's death may have been preventable: she required urgent blood transfusion which was ordered but not delivered before her collapse—Dr B. did not adequately follow up on …
32y · Male·Pulmonary embolism originating from deep vein thrombosis in right calf
…es; and absence of documented VTE risk reassessment post-operatively despite reduced mobility. An arterial blood gas was never performed despite persistent hypoxia. Earlier investigation of oxygen desaturation could hav…
Female·Coronary atherosclerosis with ischaemic small bowel and Alzheimer's disease
…ms persisted. At Hervey Bay Hospital, bowel obstruction was confirmed. Due to elevated lactate on arterial blood gas and lack of available ventilated ICU bed at Hervey Bay, she was deemed too high-risk for local surgery…
0y · Female·Persistent pulmonary hypertension in the newborn (PPHN)
…al. The coroner found Baby Summer died from PPHN but was not satisfied it was caused by sepsis despite low blood sugars and fluctuating oxygen requirements. While Dr M.'s management was generally appropriate, the corone…
12y · Female·Cardio-respiratory failure due to aspiration pneumonia
Angelique Burton-Ho, age 12, with VACTERL syndrome and difficult airway, presented to Bowral Hospital ED on 9 August 2015 with respiratory symptoms. She was inadequately triaged initially, then readmitted that evening wi…
0y · Female·Unascertained
A 9-month-old girl died suddenly on 23 July 2018 following multiple head injuries from blunt force trauma sustained shortly before death. She had presented to medical practitioners multiple times in the preceding weeks w…
21y · Female·Multiple organ failure due to undefined sepsis (toxic shock syndrome)
…shock with multi-organ failure in March 2012 after presenting with symptoms initially consistent with viral gastroenteritis and dehydration. Initial management at remote Paraburdoo Hospital was appropriate, but critical…
82y · Female·Hyperkalaemia due to acute renal failure on a background of end stage pulmonary …
An 82-year-old woman with terminal pulmonary fibrosis and chronic respiratory failure presented with chest pain, hyperkalaemia and metabolic acidosis. She became combative and was given haloperidol and morphine for agita…
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