CASE PRESENTATION
A 63-year-old man was injured by hitting a truck while driving a car. He
was hospitalised with a left pelvic fracture, multiple vertebral
fractures and multiple rib fractures. The pelvic fractures were
complicated fractures which reached pubic, ischium, ilium and the
sacroiliac joint. On admission, haemoglobin, haematocrit, and platelets
were 16.8 g/dl, 50.1%, and 217×103 /µl, respectively.
His general status was stable, except severe delirium that developed on
the 2nd to 4th day after admission.
On the 6th admission day, he underwent a
vertebroplasty of the 12th thoracic vertebra and a
posterior fixation surgery at the level between the
3rd thoracic vertebra and the 3rdlumbar vertebra. Immediately after the 6-h operation, when his body
position was changed from prone to supine in the operating room, his
blood pressure declined to 48/25 mmHg and oxygen saturation decreased
from 99% to 90% with inspiring 40% fraction of oxygen. Although these
symptoms soon improved, severe delirium relapsed when he was brought to
the general ward. The blood test performed immediately after the
operation revealed an increased serum creatinine from a baseline level
of 0.54 mg/dl to a postoperative level of 1.82 mg/dl.
On the 8th day, immediately after the postural change
in the general ward, he again suddenly lost consciousness, with the
blood pressure and heart rate being 68/26 mmHg and of 116 beats per min,
respectively. The medical emergency team was called, and he was
intubated promptly. Transthoracic echocardiography showed marked
enlargement of the right-sided heart accompanied by McConnell’s sign,
namely, akinesis of the mid free wall with apical hyperkinesis of the
right ventricle. Then, ventricular fibrillation occurred, and
cardiopulmonary resuscitation was initiated. We suspected that the
patient could have massive pulmonary thromboembolism and then initiated
venoarterial extracorporeal life support using a heart–lung machine.
Spontaneous circulation was returned 30 min after the cardiac arrest.
Life-supporting treatment, including extracorporeal membrane oxygenation
and mechanical ventilation, along with medical treatment was continued.
Despite our best efforts, he died of severe brain oedema due to
ischaemic encephalopathy on the 9th admission day.