On January 13, 2017 at or around 4:30 AM the patient, a 55 year old man presented to the ED with abdominal and back pain, inability to move his legs, decreased sensation to the lower extremities for the previous 3 hours.
Other than for hypotension (BP 84/51, HR 74), physical exam was remarkable for bilateral edematous, cool, and cyanotic lower extremities with no palpable pulses or doppler signals below the femoral arteries. Hb 10.4. Creatinine 2.0. Serum CPK 441 U/L - only slightly elevated.
A angio-CT scan of abdomen and lower extremities was performed around 5:16 AM, and showed a large right retroperitoneal hematoma (with no active bleeding) and patent arteries but decreased arterial flow below the knees. The CT report did not comment on the venous system.
A vascular surgeon (Dr. A.) was called, and over the phone she determined that no surgical intervention was indicated and that the patient should have been admitted to the ICU to treat the hypotension. No other recommendations were made. Dr. A. never saw the patient, and at around 8 AM she signed out the patient to Dr. B., the surgeon on call for the day. By 2 PM CPK had raised to > 5,000 U/L and lactate was 24.
Dr. B. met the patient for the first time at around 7:00 PM of January 13. At that time the patient’s heart rate was 104/minute and blood pressure was 119/74 mmHg. Dr. B. recognized that a leg fasciotomy was indicated at that time, but he did not feel that the patient was stable enough to tolerate an operation.
Few hours later the patient undergoes hemodialysis for K 7.2. The patient tolerated dialysis well with no hypotension. Dr. B. Did not made any plan for surgery following hemodialysis.
Since that evening of January 13 the patient had remained stable, with BP around 120/60, HR in the low 100s.
On January 14 at 5 AM CPK are 87,000. A venous duplex in the morning of January 14 confirms the diagnosis of bilateral massive venous thrombosis. On January 14 in the afternoon a recommendation is made for leg elevation.
No intervention is made until January 16, when Dr. B. decides to bring the patient to the operating room for bilateral leg and thigh fasciotomies. Pedal pulses are reestablished at the end of the procedure, however there is extensive necrosis of the leg muscles.
On January 17 the patient undergoes bilateral above the knee amputations.
I would be interested in exploring whether an earlier intervention could have resulted in salvage of the extremities.
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Do you believe there might have been medical error?
This patient presented with the classic signs ands symptoms of phlegmasia cerulea dolens, the result of massive DVT. Phlegmasia cerulea dolens is a medical and surgical emergency, but in this case a diagnosis was made with more than 12-hour delay. Even after a diagnosis was finally made no intervention was performed in the following three days. Massive DVT resulting in threat to limb viability should be treated with systemic anticoagulation and some times with mechanical/chemical thrombolysis or even surgery. Most of the time a leg fasciotomy is required to relieve the compartment pressure and preserve viability of the muscles. It is true that in this case many therapeutic options (such as systemic anticoagulation or thrombolysis) could have been precluded because of the concomitant retroperitoneal bleed, however a timely fasciotomy could have resulted in preservation of the legs.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I believe if a fasciotomy had been performed immediately after admission this patient would have had a good chance of saving his legs. There are two facts that support my opinion. 1. When a fasciotomy was finally performed, arterial circulation was re-established, as demonstrated by the presence of pedal pulses. 2. Venous return was never fully compromised, as demonstrated by the rising levels of CPK, which obviously entered the systemic circulation through venous drainage from the lower extremities, after being released by the dying musculature. Taken together those two facts support my view that a timely fasciotomy would have preserved arterial and venous circulation of the lower extremity, therefore limiting significantly the muscle necrosis and potentially saving this patient’s legs.
What makes you a good expert for this case?
I work in a large referral center. I often deal with complex clinical scenarios such as the one described, that require multidisciplinary approach and close collaboration with different medical specialties. I have prior experience as an expert witness.
How often do you encounter cases similar to this one in your practice?
Retroperitoneal hematomas are not unfrequent in anticoagulated patients, and I am consulted for this type of cases almost every month. However a retroperitoneal hematoma resulting in massive DVT is quite rare and I don't think I have ever seen one.
Do you believe there might have been medical error?
In this case a diagnosis was made more than 12 hours after surgical consultation and no intervention was performed for multiple days in spite of the fact that the patient demonstrated signs of massive DVT. This emergent condition should have triggered possible anticoagulation, thrombectomy, or fasciotomy at time of diagnosis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in diagnosis and even greater delay in treatment for this patient likely contributed to his need for amputations.
What makes you a good expert for this case?
Significant experience in management of patients requiring vascular surgery.
How often do you encounter cases similar to this one in your practice?
This is a somewhat unusual case that is rarely encountered
Do you believe there might have been medical error?
The patient had no flow to the lower extremities without a clear obstruction or external compression. Given the patent nature of his vessels a venous contrast time was a must and would have diagnosed his disease. Indeed, the normal blood pressure made the treatment team less concerned, however the patients elevated CPK and lactate spoke of an unattended and undiagnosed condition that in this case lead to amputation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I explain above why the physicians should have explored a definite diagnosis more extensively
What makes you a good expert for this case?
Exposure to these types of cases due to my scope of practice
How often do you encounter cases similar to this one in your practice?
I experience these cases frequently (thankfully they go the right way)
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Comments from similar speciality or otherwise pertinent to the case may also be accepted.