A 60 yr old male who is a known Diabetic since 10 yrs on OHA and diagnosed as having Pulmonary TB 2 montgs back and started on ATT presented to us with complaints of Loose motions with one episode of PR bleed since 1 day and Altered Sensorium since 3 hrs...At presentation, BP- 190/120 PR-70 spO2- 87 RBS- 450....Severe Pallor was present...No previous history of bleeding from any sute was present....MRI Brain showed Acute Infarct....Ketones were negative...Discuss the approach to this patient



Hyperosmolar hyperglycaemic state Suggest: Correction of dehydration Rush IV fluids,preferably insert a central venous catheter and target CVP 8-10 IV Insulin Check blood sugars every 1hrly Check Sr.Electrolytes every 6th hrly and treat accordingly Inj.Tranexamic,Inj.Vit.K PCV and FFP transfusion Suggest: LFTs Routine labs

M. O2, IV NS + RL 1:1 , 1 - 2 Lit bolus stat and sos then 6hrly, IV in Pot Chlor 20 - 40 meq > inj Sol Insulin 4 - 5 U/ hr, when sugar comes to near 200 mg% add 10% D with NS + RL, Iv 20% Mannitol 100 to 200 ml 8 hrly, Broad spectrum Antibiotics, Iv inj Tranexamic Acid 500 mg tds, inj Vit K 1 amp, Iv in pantoprazoIe 40mg bd, NTG or Hydralazine infusion, packed RBC, FFP etc. ABG 4 hrly, CBG 2 hrly. Find the cause bleeding PR and treat that. No tPA and anti Platelet therapy because that will aggravate the bleeding episode.

Resuscitation is the need... Try to take detailed history of medications... First stabilize the patient Do ACT .... DO KETONES 2 HRLY... Insulin infusion.... Creat is fine ... so start higher antibiotics... Do chest xray...rule out aspiration pneumonia....

Since repoted bpis 190/120 and bsl R 450 so both the morbid conditions are uncontrolled mri shows ac if infarct responsible for altered sensorium.so management starts from controlling pr bleeding and bsl what is the reason for pr bleeding if any antiplatelet are given should be stopped bsl controll by insulin and tackel the infarct by clexan and steroid manage bp to optimum level maintain ivfluid and electrolytes as per requirement.

How can we give clexane in bleeding p r

Thrombolysis within 24 hrs./O2 inhalation/ ABG IV fluids with soluble insulin/ Mannitol/ inj Vit k one amp stat. Broad spectrum antibiotics & ATT. LFT/sputum for AFB/ gram stain/CT abdomen to R/O mesenteric ischemia./ carotid doppler studies(neck vessels)

Send routine investigation... take two large bore iv line ... start fluid bolus ... crystalloids... urgent pcv/ffp/prc.... give tranexa ... vit k .... Sugar control... b p control... with lobetalol.... start hyperosmolar therapy .... after resuscitation ... plan csf ... send r/m ..c/s, cytology,gene expert ... it may be TBM... start dexona... start akt ... acc To lft.... look for the causes of bleeding p r ... If it’s local ... variceal ... or coagulopathy ...

Intubation is required.

Infarcts or tuberculosis brain. Kindly send your Treatment modalities

Do resuscitation if spo2 falls intubate Pt us oon att it may cause liver failure that would have bleeding

I agree with Dr V More

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