Fatal pulmonary embolism secondary to limb exsanguination

Abstract

A 57-year-old miner sustained a compound fracture of his left tibia and fibula. Six hours later, he underwent debridement and suturing of the wounds and manipulation of the fracture under general anesthesia. The leg was then splinted in a plaster of paris cast. For the next 15 days he remained in the hospital with the leg immobilized. The position of the fracture subsequently was deemed unacceptable, and he was scheduled to undergo internal fixation under general anesthesia. Preoperative assessment revealed no abnormality of the cardiovascular or respiratory systems, except for mild hypertension treated with a thiazide diuretic and potassium supplements. The chest radiograph and ECG were normal and the arterial blood pressure was 140/90 mmHg with a heart rate of 84 beats/min. Anesthesia was induced with 500 mg thiopental, iv, and muscular relaxation obtained with 45 mg d-tubocurarine, iv. The trachea was intubated, and anesthesia maintained with 66% nitrous oxide in oxygen. Ventilation was controlled using a Manley ventilator. Phenoperidine 3 mg, and droperidol 5 mg were administered iv to supplement anesthesia. The plaster of paris cast was removed from the left leg, and the entire leg was cleaned and wrapped in a sterile towel. A tourniquet was applied to the thigh. Before inflation of the tourniquet, the leg was exsanguinated by the application of an Esmarch bandage. Prior to this, cardiovascular parameters had been stable, but within one minute of the application of the Esmarch bandage cyanosis occurred and the arterial blood pressure could no longer be obtained. External cardiac massage was instituted immediately, and attempts at resuscitation were continued without success for one-half hour. Subsequent postmortem examination showed the cause of death to be multiple pulmonary emboli completely blocking both pulmonary arteries. The veins of the injured leg were found to be filled with antemortem thrombus, and it is concluded that the traumatized left leg had been the source of the emboli.