Sir,
Polytrauma in a kyphoscoliotic (KS) patient heightens the risks manifold as the physiology is already compromised. A 28-year-old male, a known case of severe KS, presented with multiple rib fractures on the right side and right tibia fracture. Blunt force trauma to the chest pointed to suspected hemothorax which was managed with intercostal drain placement (32 Fr). After initial resuscitation, tracheal intubation was attempted in view of persistent hypoxemia. Severe thoracolumbar KS was observed clinically which was later confirmed by radiography (Cobb's angle >100°) [Figure 1]. Trachea was intubated in the second attempt (as per institutional protocol) due to distorted anatomy, and the patient was shifted to the intensive care unit for further management. Bedside, echocardiography was performed (ejection fraction of 49% with normal valvular function). Computed tomography of the chest was planned to assess the nature of the injury, but the patient developed cardiopulmonary arrest secondary to hypovolemic shock which was refractory to conservative management.
Figure 1.
Chest X-ray showing multiple rib fractures on the right side with severe kyphoscoliosis
KS is due to disruption of balance between structural and dynamic components of the spine.[1] Such patients pose a challenge to anesthesiologist for surgery or intensive management.[2,3] KS with Cobb's angle >100° is rarely encountered.[4] Rib fractures distort the already compromised anatomical and physiological derangements and make the patient prone to complications, e.g. pneumonia, pulmonary effusion, acute respiratory distress syndrome, and atelectasis or lobar collapse.[5] A 30% reduced compliance along with weakened chest wall and lung parenchyma predisposes the patients to ventilation–perfusion mismatch. As the disease progresses, the patient may land into pulmonary hypertension and right heart failure. Rib cage deformity may result in kinking and compressing great vessels and ultimately causing cardiac failure.[6]
In our patient, the chest wall compliance was already compromised, but the rib fractures aggravated the insult and led to cardiopulmonary overload. KS patients with deranged status further hinder the management and may deviate the course toward more aggressive one. Complete understanding of the anatomical and pathophysiological changes warrants the need for urgent evaluation of cardiopulmonary system. Although KS is rare, it might present to an anesthesiologist in any scenario and basic understanding of the pathophysiology may change the course of treatment.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Acknowledgment
We are thankful to the Department of Anesthesia at Government Medical College, Chandigarh, for support.
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