Fatal pulmonary embolism subsequent to the use of Esmarch bandage and tourniquet: A case report and review of literature
Following a road traffic accident, a 30-year-old male developed right tibial plateau and fibular fracture. There were no other significant injuries. The limb was immobilized in a plaster cast for six days and he was planned for open reduction and internal fixation of the fracture. Due to the presence of limb edema, surgery could not be carried out till the sixth day after injury. Routine monitoring including noninvasive blood pressure, electrocardiography (ECG), and pulse oximetry were started. Spinal anesthesia was performed with 3.5 mL of hyperbaric bupivacaine 0.5%, along with buprenorphine 120 mcg. Block level of T4 was achieved and surgery was started. Approximately 40 minutes after spinal anesthesia, before starting open reduction of the tibia, exsanguination of the limb was carried out using Esmarch bandage and the tourniquet was inflated to a pressure of 300 mmHg. In the next three minutes, the patient suddenly became unconscious and his blood pressure dropped to 60/34 mmHg. Intravenous ephedrine 15 mg was given but the hypotension persisted. Endotracheal intubation was performed and full-support ventilation was initiated. Palpation of carotid artery pulsation and ECG revealed electromechanical dissociation. External cardiac compression was initiated and intravenous adrenaline of 1 mg was given every three minutes. For the brief duration of ventricular fibrillation which developed, defibrillation was done. It was suspected to be due to PE; hence, heparin 5,000 IU was given intravenously about 20 minutes after the arrest. After about 30 minutes of cardiopulmonary resuscitation (CPR), spontaneous circulation returned. Infusion of dopamine was started for hypotension. Surgery was abandoned and the patient was shifted to the intensive care unit (ICU) for further management. In the ICU, transthoracic echocardiography revealed right atrial and right ventricular dilatation and tricuspid regurgitation. Serum level of D-dimer was increased (>5,000 ng/mL), and Doppler study of the lower limb indicated the presence of thrombus in right femoral vein, confirming deep venous thrombosis (DVT) and PE as the diagnosis. Thrombolysis was started with intravenous streptokinase 500,000 IU. Intravenous infusion of heparinwas continued at 1,000 IU/hour to maintain activated partial thromboplastin time (aPTT) for around 90 seconds (three times control). Infusion of dopamine was stopped following normalization of blood pressure. Cerebral protective measures like mannitol, phenytoin, and dexamethasone were started from the second day. The patient never had a complete neurological recovery. Four days after the event, magnetic resonance imaging (MRI) of the brain revealed diffuse hyperintense signals in bilateral areas of the cerebral hemisphere, suggestive of diffuse cerebral edema. There was obliteration of the basal cistern and herniation of cerebellar tonsils. His neurological status deteriorated further in the next five days. The patient did not have a neurological recovery and died on the ninth day after the surgery.