The March 2018 edition of Clinical Communiqué reviews coroner cases involving a gas embolism. Gas embolism may be a relatively rare clinical entity, but it is a diagnosis that must remain at the forefront of our minds when planning and performing any invasive procedures. Even minimally invasive procedures such as infusing intravenous fluids.
‘Case Number: 2009/355 Qld Case Précis Author: Dr Nicola Cunningham B.Med, MForensMed, FFCFM (RCPA), FACEM
Mr DS was a 34-year-old male who fell at work, fracturing his right clavicle. He was seen at a local emergency department where he was provided with pain relief and a sling. An x-ray showed a midshaft comminuted fracture of his right clavicle with marked displacement, so he was referred to a private orthopaedic surgeon for follow up. One month later, a repeat x-ray showed a butterfly fragment of the clavicle, for which the surgeon recommended internal fixation and grafting.
Arrangements were made for Mr DS to be admitted to a private hospital the following month to undergo the elective procedure under a general anaesthetic. The operation involved fixation of a plate to the clavicle using screws inserted into holes drilled by the surgeon. An elevator plate was placed under the clavicle to protect the underlying tissues. On withdrawing the drill bit from the final (and most medial) hole, a large amount of dark blood sprayed out of the drill guide. The surgeon found a puncture in the top of the right subclavian vein and was able to control the bleeding with direct pressure and two vascular loops, however, Mr DS rapidly developed circulatory shock.
Over the next 30 minutes, Mr DS received fluids and blood, and cardiopulmonary resuscitation was commenced with no improvement. Two chest drains were positioned presumptively to exclude a tension pneumothorax as the cause of his deterioration. A vascular surgeon was urgently called to assist, who considered the possibility of an air embolus. A single-bore central venous catheter was inserted, at which point the diagnosis of an air embolus was further suspected when approximately 20-30mls of air was aspirated from the right atrium before any blood. Mr DS was unable to be resuscitated and died on the operating table, three and a half hours after the start of his procedure.
The forensic pathologist conducted a postmortem examination and CT scan of Mr DS. He also reviewed the medical charts and spoke to the surgeon before finalising his autopsy report. It was estimated that 2.5 to 3L of blood had been lost intraoperatively, and a tension pneumothorax was not proved at any stage. The cause of death was listed by the pathologist as fractured right clavicle (surgery) due to, or as a consequence of, a fall.
The Queensland police service were initially called to investigate the circumstances of Mr DS’s death, and statements were taken from the surgeon and anaesthetist. The coroner subsequently received statements from the theatre nurses and the companies that manufactured and distributed the plates and the drill equipment. Expert opinions were obtained from an orthopaedic surgeon, an anaesthetist and a biomedical engineer.
At inquest, the coroner focussed on: how the subclavian vein was perforated; whether the equipment was used appropriately and had adequate safeguards in its design; what policies and procedures were in place at the hospital; and whether the management of the complications that occurred was adequate.
Expert opinions suggested that the decision to proceed to surgery and the choice of equipment used were appropriate in the given circumstances. Likewise, the management that took place when Mr DS developed severe shock was reasonable. The clinical experts agreed that even if the diagnosis had been made earlier, the outcome may not have differed. The coroner noted that there had not been any previously reported incidents in the manufacturers’ databases about perforation of blood vessels using the plate systems or the drill in question.
The coroner found that Mr DS died as a result of air embolism and severe haemorrhage, from perforation of the right subclavian vein during surgery for the repair of a fractured right clavicle. There was no evidence to suggest that the surgical equipment used was faulty. The coroner referred the case to the Royal College of Surgeons, the Royal College of Anaesthetists of Australia and New Zealand, and to the Shoulder and Elbow Society of Australia, as a case study for discussion and learning amongst its members.’
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