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Severe Head Trauma and Fractures: Case Study of a 27-Year-Old Male Patient

This case study discusses a 27-year-old male patient who was admitted to the emergency room following a severe head injury after a suspected fall. Initial evaluations revealed a Glasgow Coma Scale (GCS) of E1V1M1 and multiple fractures, including subarachnoid hemorrhage and maxillary and mandible fractures. Immediate resuscitation and diagnostic imaging highlighted critical injuries, leading to intensive care management. The patient's past history of IV drug abuse and the possibility of ongoing shock were also considered in the treatment plan.

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Severe Head Trauma and Fractures: Case Study of a 27-Year-Old Male Patient

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  1. Case Conference Int.林美琪 96/04/03

  2. Patient profile • 李季, 27y/o, male • Chart num.:16897970 • Admission to ER date: 96/03/30 04:36 • Way of admission: 119 • Discharge from ER date: 96/03/31 12:30

  3. Injury mechanism • According to the inhabitant’s description, a great sound “bump” was heard. Falling down was suspected, but there is no witness. • 現場生命徵象: Coma(E1V1M1)

  4. Pre-hospital evaluation and management • sent to KMUH ER • Head: ILOC(+), dizziness(?), headache(?), nausea/vomiting(?), amnesia(?), vertigo(?) • Neck: pain(?), stiff(?), soreness(?) • Chest: pain(?), dyspnea(?) • Abdomen: pain(?), discomfort(?) • Limbs and skin : Bilateral forearm deformity, Right knee abrasion wound, Face deep laceration wound, Mandible deformity • 頸圈, 長背板固定, 左右手木板固定, 傷口包紮, 評估意識及生命跡象

  5. Initial evaluation (KMUH) A (airway) / B (breathing): • RR:20cpm, SpO2:70% • Collar fixation: need • Airway: respiration: not smooth airway obstruction sign: cyanotic and strider blood in the mouth trachea: mid-position breathing sound: bilateral rales

  6. C (circulation): • Rate: 64 bpm brachial a.: normal carotid a. : normal femoral a.: normal dorsalis pedis a.: normal • Cuff BP: 123/104 mmHg • Skin condition: appearance: not pale temp: warm (36.2’C) humidity: normal • Suspect: facial bone fracture and subcutaneous hematoma

  7. D (disable): • GCS: E1V1M1 • Pupil : od: 1mm, (-/-) os: 4mm, (-/-)

  8. E (exposure): • L’t face deep laceration (7cm) • L’t and R’t forearm deformity • R’t knee abrasions wound • No bruise over bilateral buttock and hip area • No urethra meatus bloody discharge

  9. Initial Resuscitation • On endotracheal tube (#7.5, fix 22cm) and assist ventilation • RR:24/min, TV:700ml, FiO2:40% • Maintain cardiac monitor • Insert 2 large-born IV line and rapid infusion of crystalloid solution (N/S and L/R) • On CVC • On foley and OG • Collect blood sample and urine routine for initial laboratory studies

  10. Initial Radiographic Studies • Brain CT (without contrast) • subarachnoid hemorrhage in left Sylvian fissure, left fronto-parietal regions and basal cistern • brain edema • skull base fracture • bilateral maxillary and mandible fracture • hemosinus in all paranasal sinuses • FAST : no intra-abdominal free fluid accumulation

  11. Left forearm AP and Lat X-ray • left distal radial and ulnar fracture, closed • Right forearm AP and Lat X-ray • Right knee AP and Lat X-ray • Right elbow AP and Lat X-ray • right humeral fracture, closed • Chest X-ray

  12. 12-Lead EKG • C-spine CT • Subarachnoid hemorrhage in the basal cistern and extending into cervical thecal sac. • Fractures of left posterior tubercle & left inferior articular facet of C6, left posterior tubercle of C7, left transverse process of T1, T2, and left 1st, 2nd ribs. • Pelvis CT • No image evidence of pelvic fracture

  13. Past history • IV drug abuser (heroin addiction) • DM (-) • HTN (-) • Hepatitis B or C carrier: denied • Op. hx.: denied • Allergy hx.: denied • Family hx.: non-contributory

  14. Lab data

  15. Tentative diagnosis • head injury /c skull base fracture /c traumatic SAH • bilateral maxillary and mandible fracture • right humeral fracture, closed • left distal radial and ulnar fracture, closed

  16. Ongoing Evaluation & Resuscitation • Monitor vital sign and conscious level • Evaluate the evidence of new or ongoing signs of shock • Antibiotics usage: cefazolin + GM • Keep patients warm • Consult NS: admitted to NS ICU for further care • Consult OW: casting the elbow and forearm fracture

  17. After admission • 03/31 PM4:35: BP drop and pulseless • Bosmin 1 Amp iv. • Dopamin 4 Amp + N/S 500ml Keep 30 ml/hr • Sigh DNR, then AAD

  18. Thanks for your attention!!

  19. maxillary fracture mandible fracture hemosinus

  20. Subarachnoid hemorrhage sphenoid bone (skull base) fracture Brain edema

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