e-CASES: Cranioencephalic injuries, limb injuries, aspiration pneumonia
33-year old patient, road traffic accident, motorbike collided with light vehicle, front impact with no helmet.
At the arrival of the Fire department: coma, Glasgow = 3, bilateral mydriasis, gasp, emergency intubation, state of shock with blood pressure of 64/40, pulse: 140, not possible to measure saturation.
Induction and intubation. Lesions observed: open left tibia-fibular fracture, displaced closed fracture of the left wrist, reduced on site, possible fracture of the left femur, hemoptoic bronchial aspirations, exposure of external genitalia.
On arrival at the university hospital:
. no abdominal guarding or contracture,
. no thoracic deformation but decrease in right basal breath sounds,
. no pelvic instability,
. neurological aspects: symmetric intermediate pupils, significant facial wounds with bleeding: right superciliary arch, submental wound, auricle, earlobe and lips,
. hemodynamic aspects: heart rate = 80, blood pressure = 95/30 after intravenous fluid therapy with 2 liters of colloids, peripheral pulses detected in upper and right lower extremities but absent in left lower extremity, left foot cold, skin capillary refill time more than 3 seconds. Temperature 33.7°C, peripheral O2 saturation 100% under high oxygen concentration, exposure of external genitalia.
The body scan is provided with an angiography scan of the lower extremities given the suspicion of an arterial wound.
- Investigation with high degree of artefacts: moderate cerebral edema with inferior visibility of the right cortical sulci probably due to the presence of a subarachnoid hemorrhage in the sulci and in the interpeduncular cistern.
- Right fronto-orbital subcutaneous hematoma.
- Infectious filling of the sphenoid sinuses (no fracture of the base of the skull).
- No other intracerebral posttraumatic lesions.
No posttraumatic lesions.
Obstruction of the segmental bronchi of the middle and inferior right lobes with downstream atelectasis suggestive of inhalation pneumopathy.
No other posttraumatic lesions.
Right subdiaphragmatic pooling with air bubbles at that level, extending into the retroperitoneum to the rear of the 3rd duodenum and at the level of the right anterior pararenal space suggestive of rupture of the esophagogastric junction and/or rupture of the right pillar of the diaphragm: to be supplemented with CT oral opacification.
No other intra-abdominal posttraumatic lesions.
On the right, displaced fracture of the femoral diaphysis with normal permeability of the arterial axes distally.
On the left: shattered bones with "floating knee" associated with a significantly displaced fracture of the femoral diaphysis and displaced comminuted diaphyso-epiphyseal quadrifocal factures of both leg bones. Open bimalleolar fracture and fracture of the calcaneus.
Opacification of the superficial femoral artery and of the popliteal artery to the level of the acetabular notch. No extravasation of contrast medium. This appearance is indicative of vascular injury: either occlusive dissection, arterial rupture with "protective" spasm, or, less likely, a peripheral embolus.
Cranioencephalic injuries, limb injuries, aspiration pneumonia
Hemorrhagic shock following polytrauma: polytransfusion (10 red cell packs and 5 fresh frozen plasma packs), placement of a central venous line and an arterial catheter.
. Sudden desaturation at around 4 a.m. The chest X-ray shows complete atelectasis of the right lung necessitating fibroscopic aspiration of old blood.
. Examination of external genitalia by the urologist: scrotal wound measuring approximately 8 cm opposite the median raphe and exposing both testicles. Patient sedated, field scrubbed with betadine, scrotal investigation revealed testicles of normal size and consistency, epididymis in place, no hematocele, no injury to the bulbar urethra, closure of flaps, compressive dressing and placement of a silicone urinary catheter, no particular problems.
. Immobilization of right leg with plaster cast boot.
. Consultation of vascular and orthopedic surgeons with joint decision to amputate the left leg (no possibility of segmental revascularization on the leg): Gritti amputation to retain as much length as possible and enable subsequent osteosynthesis of the femur.
Inspection of scan at H12:
. Skull: mild increase in cerebral edema, onset of right temporo-polar centrimetric intra-axial hemorrhagic contusion, subarachnoid hemorrhage visible on the interpeduncular cistern and some frontoparietal cortical sulci, right frontal extra-axial hemorrhagic layer with no mass effect, unchanged ventricular system volume, median structures in place.
. Thorax: no leakage of contrast medium from esophagogastric junction after opacification, disappearance of previously visible extra-intestinal air pockets, almost complete disappearance of right subdiaphragmatic pooling.
- diaphragmatic trauma is never isolated; therefore, in our case, it could be ruled out in view of the absence of other thoracic and abdominal lesions.
- An abrupt interruption in arterial opacification in a traumatic context may indicate an arterial spasm, occlusive dissection, extrinsic compression, or an embolus.
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