e-CASES: Craniocerebral trauma, Pulmonary edema, Renal injury
18-year old patient, severe cranial injury following road traffic accident: collision between scooter and light vehicle, front impact, expulsion of helmet during accident.
Initial clinical examination:
- Glasgow = 7 at start of care, deviation of eyes to right, reactive, symmetric pupils.- Reduction in normal breath sounds over right pulmonary field,- Stable hemodynamics, blood pressure: 130/70 mmHg, heart rate: 69, oxygen saturation: 100%,- Soft, painless abdomen.
After intubation, degradation of hemodynamics, requiring massive intravenous fluid therapy.On the arrival of the emergency services, blood pressure: 80/40 mmHg, heart rate: 65, oxygen saturation: 100%. Instigation of Norepinephrine treatment for hemodynamic support and transfer to university hospital after intravenous administration of 2 l of colloids and 1.5 l of crystalloids.
The body scan is provided.
- Diffuse axonal lesions in the left frontal region and in the left semi-oval center.
- Left temporal extradural hematoma with air pockets associated with an extralabyrinthic fracture of the petrous bone.
- Left temporal petechial contusions.
- Deep, left medial temporal intra-parenchymatous hematoma.
- Moderate cerebral edema, no herniation.
- Right frontotemporal subcutaneous hematoma.
- Fracture of the middle stage of the base of the skull (and contact emphysema of soft tissues) with:• Fracture of the left temporal section extending to the left petrous bone with an extralabyrinthic trajectory (integrity of ossicular chain) and damage to the tegmen tympanii. Pneumencephalus at this point (osteomeningeal breach very likely);• The line then extends to the sphenoid via the anterior part of the carotid canal followed by the antero-inferior and right lateral walls of the sphenoid sinus (with hemosinus and intrasinus bone fragment).• And at the front, fracture of the posterior part of the vomer bone.
N.B.: left nasal packing- Cervico-dorso-lumbar spine: no posttraumatic bone lesions
- Cardiogenic pulmonary overload++ (thickening of the septa, ground glass opacities, gravity-dependant areas of opacification and edematous infiltrate of the mediastinum).
- Probable associated pulmonary contusions particularly in the upper left lobe and both inferior lobes.
- Minor bilateral pneumothorax.- No traumatic lesions of the mediastinal large vessels.
- Signs of excessive filling (periportal edema, liquid effusion of the vesicular bed, perisplenic fluid layer);
- Right mediorenal deep laceration with contact hemoretroperitoneum, with no active bleeding or damage to the collecting ducts (no urinary extravasation at this delayed point in time).
- Hematuria with intravesical fluid line.
- No other posttraumatic lesions.
Craniocerebral trauma, Pulmonary edema, Renal injury
- Placement of an intracerebral pressure (ICP) probe; the pressure was initially elevated: administration of osmotherapy with use of vasopressor amines to maintain satisfactory intracerebral hemodynamics, normalization of ICP on the second day. Favorable progress with discontinuation of sedation on the 5th day, no sensorimotor deficiency observed, no cognitive or behavioral deficiency was reported.
- Posterior packing in the left nostril for persistent posterior epistaxis.
- Simple monitoring of the right renal injury with favorable progression.
- The diffuse axonal lesions and the deep hematomas are shearing lesions and are situated in specific regions.
- The presence of air in an extradural hematoma is indicative of a probable homolateral fracture of the petrous bone.
- With petrous bone fractures, it is important to note whether it is trans- or extralabyrinthic, and report any damage to the ossicular chain and tegmen tympanii.
- Look for signs of hemodynamic overload (periportal edema, pulmonary edema, edematous infiltration of the mediastinum and/or subcutaneous fat tissues, etc.).