e-CASES: Cranioencephalic trauma, Facial fracture, Thoracic injuries, Pelvic fracture, Spleen and renal trauma
Fall of a few meters following a loop while paragliding:
Glasgow 15 at start of care, hemoglobin 14.4g/dl, blood pressure 11/6, pulse 104, saturation 92%.
Auscultation normal, abdomen soft. No audible heart murmur. Medical transport to university hospital.
On arrival at the university hospital, onset of left anisocoria in spite of Glasgow of 15, decision to intubate after induction and sedation, placement of a left subclavian central venous line followed by hemodynamic instability requiring intravenous fluid therapy with 1 l of saline and introduction of Norepinephrine 1 mg/hr, infusion of Mannitol due to mydriasis. Onset of a cogwheel holosystolic murmur at all foci that can be auscultated. Cardiac ultrasonography revealed interventricular communication with systolic pulmonary arterial pressures measured at 50 mmHg, with no right cavity dilation and no paradoxical septum.
Full body scan performed.
- 3 mm thick right parietal subdural hematoma with no mass effect extending to the posterior part of the falx cerebri. - Some left parafalcine frontal petechial contusions.- Left periorbital hematoma associated with a left naso-ethmoid-maxillo-orbital fracture associating: Fracture of the orbital floor passing through the suborbital canal, with no muscle or fat incarceration: Fracture of the lamina papyracea with no incarceration; Fracture of the frontal process of the maxilla; Fracture of the nasal bones and the inferior nasal spine.- No posttraumatic lesions of the cervicoencephalic arteries.
- Multiple images of bilateral parenchymatous opacification predominating in the right posterior regions, suggestive of pulmonary contusions with some pneumatoceles on the right. - Layer of right pneumothorax. - Some pockets of precardiac pneumomediastinum and small right paratracheal air pocket, which appears to correspond to a filled segmental bronchus rather than to a pneumomediastinum, may require further examination. - Fractures of the 7th to 9th right ribs at the costochondral junctions.
- Minor contusion of the inferior pole of the spleen, with no active bleeding. - Dissection of the proximal third of the inferior polar artery of the left kidney with downstream inferior polar parenchymatous infarction. No active bleeding.- No significant intraperitoneal fluid effusion. Hemoretroperitoneum associated with pelvic fractures.- H-shaped fracture of the sacrum with minor active left lateral sacral artery bleeding.- Fracture of the right transverse process of L5 with minor active distal contact bleeding of a lumbar arteriole. - Non-displaced fractures of the left ilio- and ischiopubic branches with minor venous bleeding in contact with the left ischiopubic fracture site.
Cranioencephalic trauma, Facial fracture, Thoracic injuries, Pelvic fracture, Spleen and renal trauma
- It was decided to monitor the interventricular communication located in the center of the muscle mass (distal third of the interventricular septum) as right pressures were unaffected. This interventricular communication will be closed in a second phase (2 months after the accident) to facilitate prosthetic placement.
- Orthopedic treatment of pelvic fractures with long-term bed rest (3 months).
- Post-repair fracture of the left humeral blade.
- Conservative treatment of the facial fractures.
- Incarceration of the deprimens oculi is suspected if it is trapped in the fracture site and/or if it has migrated downward and/or if it has a rounded and globular shape in a cross-sectional view.
- Renal infraction (which is systematized to one arterial region and has clear boundaries) should not be mistaken for renal contusion (which is not systematized, has irregular contours and is very often accompanied by contact hemoretroperitoneum).
- Whenever one fracture line is found in the pelvis, a second should always be sought.