Introduction
The number of deaths worldwide due to vehicular accidents remains unacceptably high, with an estimated 1.35 million people dying each year.[1] Road traffic injuries are the eighth leading cause of global death across all age groups[1] and the second leading cause of death in the age group between 15 and 39 years for both sexes combined in India in 2017.[2] Exsanguinating hemorrhage remains the second most common cause of death after trauma preceded by head injury.[3] Early recognition and aggressive management increase the chance of survival. Definitive bleeding control is essential along with appropriate intravascular volume replacement and that most patients respond to these principles of management. However, some patients fail to improve with resuscitation, where it becomes essential to identify other sources of hemorrhage or rule out other causes of shock. Therefore, this case report aimed to prove that the soft tissue compartment is a potential and deceiving site of bleeding, and its early recognition is essential for improving outcomes in these subgroups of patients. We present the case of a 19-year-old man with concealed bleeding into the soft tissue compartment posing a challenge in managing the patient.
Case presentation
A 19-year-old man visited our emergency department at approximately 3 hours 20 minutes after a suspected history of 2-wheeler skid. He was a nonhelmeted rider and was brought by his relatives after taking him to a nearby civil hospital where he received initial treatment, such as fluid resuscitation (500 mL of ringer lactate) and intravenous analgesia. The patient also had an episode of generalized seizures, which resolved spontaneously. He was then referred to our hospital because of polytrauma and was brought to our emergency department by his relatives with oxygen via facial mask at 8 L/min but without any prior notice. This is because our trauma and referral system is still improving.
Upon initial assessment, the patient had a patent airway and was breathing spontaneously. However, he was tachycardic with a pulse rate of 117 beats/min, blood pressure of 90/60 mmHg, and a Glasgow Come Scale (GCS) score of 9 of 15 with normal pupillary reaction. All 4 limbs were moving without any focal deficit suggestive of any intracranial injury. Extended focused assessment with sonography in trauma was negative, and a chest radiograph (Fig. 1A) revealed huge swelling over the right side of the chest. His allergies, medications, past medical history, last meal, event history was insignificant without previous episodes of seizure or head injury. Subsequently, on secondary survey, a nonpulsatile/nonexpansile swelling was noted on the right side of the chest wall (Fig. 1B). Resuscitation was started according to the Advanced Trauma Life Support protocol, including warm crystalloids (1 L of ringer lactate) and routine laboratory tests, such as blood crossmatch. During resuscitation, the patient’s blood pressure dropped to 70/46 mmHg with a GCS of 7 of 15. He was then intubated and reevaluated. Repeat extended focused assessment with sonography in trauma was also negative. A massive blood transfusion protocol was initiated based on the clinical and physiological status of the patient. Right-sided intercostal drainage tube of 30 Fr was inserted because of worsened shock and right hemithorax swelling, which drained minimal output. However, he did not respond to the ongoing resuscitation, including with blood product transfusion. Arterial blood gas analysis showed severe metabolic acidosis with elevated lactate and base deficit suggestive of class 3 shock with adequate ventilation (pH, 7.22; lactate, 6 mmol/L; base excess, −7 mmol/L; pO2, 114 mmHg; pCO2, 34 mmHg; Ca2+, 0.9 mmol/L). Because we were not sure of the hemorrhage site, which have led to refractory shock, we performed noncontrast computed tomography of the head and cervical spine and contrast-enhanced computed tomography of the torso. Immediately after imaging, the patient had an episode of cardiac arrest and was revived after 5 minutes of cardiopulmonary resuscitation. However, after 10 minutes, the patient developed another episode of cardiac arrest and unfortunately died despite performing a 45-minute cardiopulmonary resuscitation. The patient was also coronavirus disease positive.
;)
Figure 1: Huge swelling in the right side chest and right shoulder. (A) Chest radiograph showing soft tissue swelling in the right lateral side of the chest wall. (B) Clinical picture of the chest and shoulder showing huge swelling over the left shoulder and right lateral sides of the chest wall.
Contrast-enhanced computed tomography torso revealed a right scapular fracture with a large soft tissue hematoma along the right side of the neck and chest wall, extending up to the right lumbar region with high attenuation contrast deposited in the soft tissues in the right axillary and subscapular region (Fig. 2). No significant intrathoracic and abdominal injuries were found on imaging. Computed tomography head and spine yielded normal findings.
Figure 2: Contrast-enhanced computed tomography chest suggestive of large soft tissue hematoma. (A) High attenuation contrast deposited in the soft tissues in the right axillary and subscapular regions. (B) Coronal image of computed tomography showing large soft tissue hematoma along the right side of the chest wall, shoulder and extending up to the right lumbar region. (C) Volume rendering technique reconstructed images of the chest computed tomography.
Although the presentation closely mimics scapula-thoracic dissociation, it defers from the same in having intact distal pulsations with comminuted fracture of the scapula and not lateral scapular displacement.[4]
Discussion
A universal rule in trauma is to consider posttraumatic shock as a hemorrhagic shock unless proven otherwise. However, in clinical practice, scenarios that are not straightforward and overlap with other causes of shock exist. The clinical dilemma was that this patient had an obscure source of hemorrhage even after the initial assessment and adjuncts, which was further complicated by the history of vomiting, seizures, and poor GCS score. We retrospectively analyzed this case at our mortality meet and realized certain important but usually overlooked caveats of resuscitation, which we would like to reiterate in the hope that it would make us wiser with our next encounter with a similar case. Thus, we would like to share the following insights.
In the current case, the bleeding was into the soft tissue compartment, which is usually overlooked as a potential space for bleeding. Soft tissue injuries are common after blunt trauma. Morel-Lavallée lesion or closed degloving injury occurs when the skin and subcutaneous tissue are abruptly separated from the underlying fascia after trauma.[5] This disrupts the perforating vessels and lymphatics, thus creating a potential space filled with fluid commonly seen in the peritrochanteric region and proximal thigh. Rarely, the area involved could be very large, thus creating a huge potential space. However, the soft tissue compartment is also a potential space for bleeding, leading to hemorrhagic shock. A few cases of patients in shock due to Morel-Lavallée lesions have been reported, and all of those were around the pelvis/acetabulum (Table 1). Death from Morel-Lavallée lesions has been rarely reported in the literature.[11] In our case, the unusual location of the soft tissue compartment bleeding was notable.
Table 1 -
Analysis of Papers Where Subcutaneous Bleeding Was a Source of Shock
| Study |
Bleeding Location |
Management |
Outcome |
| Hefny et al.[6]
|
Extensive hematoma between the subcutaneous fat and the paraspinal muscles in the back |
Percutaneous suction drain |
Discharged |
| Yumoto et al.[7]
|
Large hematoma in the lower back with lumbar vertebrae fractures with active contrast extravasation at multiple sites located close to the bilateral lumbar and internal iliac arteries |
Gel foam embolization |
Discharged |
| Mao et al.[8]
|
Left flank to thigh |
NOM but later required open drainage for infected collection |
Discharged |
| Claassen et al.[9]
|
Lower lumbar region in the back |
NOM |
Discharged |
| Daghmouri et al.[10]
|
Lumbar region extending to hips and both legs |
Surgical drainage |
Discharged |
NOM, nonoperative management.
This patient had a hematoma in his upper chest wall and venous injury, which we determined after a computed tomography scan. Although it is advised to avoid the injured limb for any resuscitation, the absence of any fractures or external injuries to the upper limb in this patient suggested that the vascular system was intact. In addition, we assumed that the parts of fluids and blood products administered through the right upper limb could not reach the systemic circulation and further exacerbated the shock, which resulted in poor response to resuscitation. Coagulopathy in trauma is among the most controversial topic. For example, the >3-hour delay contributed to the worsening of coagulopathy, leading to poor response to our resuscitation. Because of lack of viscoelastic assays in our country, it is impossible to rule out the possibility.
The proposed definitive management of this patient also generated various arguments and was divided into 2 schools of thought, although various options have been proposed for the management of Morel-Lavallée lesions from compression dressings to debridement, percutaneous drainage, and administration of sclerosing agents as well as interventional radiological methods in cases where the patient’s condition allows for embolization of active bleeders.[12] As our patient was in shock, we had 2 options. First was to operate on the patient and cut open through the swelling, identify and ligate any obvious bleeder, or pack the cavity. The second option was to resuscitate the patient and wait for the bleeding to stop by the body’s natural mechanism of thrombosis, as the skin was intact with the weight of the body, providing the required tamponade.[9] Therefore, when our patient did not respond to blood product resuscitation, a timely decision should be made, such as rushing him to the operating room to manage the bleeding. Soft tissue compartment bleeding like those usual hemorrhage sites presents with features of shock, such as tachycardia, hypotension, altered mental status, and decreased urine output with metabolic acidosis. However, subtle signs of trauma like bruise or abrasion with swelling may be present with or without underlying fractures, which may be difficult to identify in the preliminary examination. Hence, if a patient with suspected hemorrhagic shock does not respond to resuscitation, it may be a clinically wise decision to repeat a detailed head-to-toe examination to rule out soft tissue compartment bleeding.
Conclusion
To our knowledge, this is the first study on closed scapular fractures or isolated blunt upper limb venous injury that caused bleeding into the soft tissue compartment leading to the death of a patient. Therefore, we suggest that the soft tissue compartment is the sixth potential site of internal bleeding in trauma patients, which should not be overlooked after having ruled out the other 5 sites. We propose to use the term iceberg phenomenon because the bleeding is more concealed in such cases and that “what meets the eye is just the tip of the iceberg.” Therefore, further study is required to identify deficiencies in the management of closed soft tissue injuries, especially those presenting with hemodynamic instability to improve the patient outcomes.
Learning points
- Early hemorrhage control is the norm in all cases of traumatic shock.
- Soft tissue compartment bleed is usually concealed hemorrhage and can deceive the treating surgeons unless one is honed to look out for it.
- In the absence of a specific guideline/protocol for the management of soft tissue compartment bleeding, treatment should be individualized based on the hemodynamic status of the patient.
Conflict of interest statement
The authors declare no conflict of interest.
Author contributions
Vaidyanathan R, Dar PMUD, Bagaria D, and Gupta A formulated the current study idea. Vaidyanathan R and Dar PMUD extracted the case data and wrote the first draft of the manuscript. Bagaria D and Gupta A critically commented on the manuscript, revised it, and approved the final version.
Funding
None.
Ethical approval of studies and informed consent
The Ethics Committee of All India Institute of Medical Sciences states that the publication of case reports is exempt from ethics approval. Written informed consent was signed by the patient’s father because the patient died during the treatment. This manuscript has the consent of the patient’s father for the use of data and for the publication of the data that appear in the article.
Acknowledgments
None.
References
1. World Health Organization. Global status report on road safety 2018. Accessed February 20, 2022.
https://apps.who.int/iris/handle/10665/276462
2. India State-Level Disease Burden Initiative Road Injury Collaborators. Mortality due to road injuries in the states of India: the Global Burden of Disease Study 1990–2017.
Lancet Public Health. 2020;5(2):e86–e98. doi:10.1016/S2468-2667(19)30246-4
3. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of
trauma deaths: a reassessment.
J Trauma. 1995;38(2):185–193. doi:10.1097/00005373-199502000-00006
4. Rubenstein JD, Ebraheim NA, Kellam JF. Traumatic scapulothoracic dissociation.
Radiology. 1985;157(2):297–298. doi:10.1148/radiology.157.2.4048434
5. Morel-Lavallée VAL: Decollements traumatiques de la peau et des couches sous jacentes.
Arch Gen Med. 1863;1:20–38, 172–200, 300–332.
6. Hefny AF, Kaka LN, Salim EN, Al Khoury NN. Unusual case of life threatening subcutaneous hemorrhage in a blunt
trauma patient.
Int J Surg Case Rep. 2015;15:119–122. doi:10.1016/j.ijscr.2015.08.035
7. Yumoto T, Sato K, Ugawa T, Ujike Y. An unusual case of a patient who presented with haemorrhagic shock following massive subcutaneous haematomas of the lower back due to blunt
trauma.
BMJ Case Rep. 2015;2015:bcr2015211645. doi:10.1136/bcr-2015-211645
8. Mao RD, Tan EP, Goh HK. An unusual cause of haemorrhagic shock from a subcutaneous haematoma: a morel-lavallée lesion.
Singapore Med J. 2015;56(4):e62–e64. doi:10.11622/smedj.2015063
9. Claassen L, Franssen MA, Robert de Loos E. A rare case of hemorrhagic shock: Morel-lavallée lesion.
Clin Pract Cases Emerg Med. 2019;3(4):417–420. doi:10.5811/cpcem.2019.9.43674
10. Daghmouri MA, Ben Ismail I, Ouesleti M, et al. Morel-Lavallée lesion as an unusual cause of hemorrhagic shock: case report and review of literature.
Int J Surg Case Rep. 2020;77:759–761. doi:10.1016/j.ijscr.2020.11.108
11. Rashid A, Singh MK, Feng SS, Yatim NM, Sahak MY, Mahmud R. Lethal morel-lavallée lesion: a forensic radiology-pathology correlation.
Radiol Case Rep. 2020;15(8):1280–1284. doi:10.1016/j.radcr.2020.04.054
12. Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallée lesion.
J Trauma. 1997;42(6):1046–1051. doi:10.1097/00005373-199706000-00010
