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I ran over my own face

This case details a patient who ran over their own face, presenting with significant facial trauma, multiple lacerations, and airway compromise. Initial assessments found the patient conscious but struggling to speak, with blood in the mouth and significant swelling. Despite airway management and intubation efforts, the patient exhibited continued bleeding and neurologic deterioration. CT imaging revealed fractures and possible cerebral infarction. The management involved extensive blood transfusions, interventional radiology for embolization, and consultations with plastics and ophthalmology. The case highlights the intricate challenges faced in trauma care.

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I ran over my own face

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  1. I ran over my own face Raj Upadhyay R3 –CCFP/EM

  2. Urgence Sante` • 77 M, found conscious under his car • Has multiple lacerations and bleeds on his face • 21:43 -- 140/80, RR 20, P84, 100% on 15L • Arrives in ER 22:14

  3. Pt. is in the Trauma Bay…

  4. Airway Assessment • Pt having difficulty speaking • ++blood in the mouth • Significant facial trauma; looks swollen and deformed

  5. Airway Assessment Continued • No subcutaneous emphysema • No obvious laryngeal trauma • Trachaea midline • Short fat neck, small mouth

  6. Airway Management • Blood suctioned with no avail • RSI --Etomidate 30 + Succinylcholine 100 • Relatively difficult intubation • Tube placement confirmed by qualitative CO2 detector and auscultation

  7. Breathing Assesment • Good A/E bilaterally • O2 sats 100% on FiO2 of 50% • Remainder unremarkable

  8. Circulation Assesment • BP now 183/72 • P 80 • Good peripheral circulation • Other than the face, no obvious source of bleeding

  9. Disability • Difficulty opening his eyes secondary to swelling • Difficulty talking • Initially and may have been confused in the ambulance • Overall GCS 14-15/15

  10. Exposure • Left scalp hematoma • Bilateral periorbital ecchymosis • Multiple lacerations around the lips, chin, and forehead oozing significant quantity of blood • Abrasions and lacerations on both hands and feet

  11. Adjuncts • Foley and NGT inserted • Fast ultrasound normal • CXR widened mediastinum with no hemo/pneumo-thorax • ETT placement appropriate

  12. Secondary Survey • Hyphema of left eye with upper and lower lid hematoma • Laceration of lt medial canthus; no obvious corneal lacerations

  13. Secondary Survey Continued • Blood in the nares and mouth with multiple cuts inside the mouth • Periorbital ecchymosis and swelling • No other signs of basal skull fracture

  14. Secondary Survey Continued • Step deformity in the lt zygoma • Nil in neck, chest, abdo, pelvis • No step-deformities in TLS spines • No blood in the rectum

  15. AMPLE • Paramedics have some of his pills that his frantic wife handed to them: • Coumadin, altace, diltiazam, HCTZ

  16. Ample Continued • No known allergies • History of high blood pressure and some strokes in the past • Last meal supper that night • Significant ETOH abuse

  17. Event History

  18. Further Investigations/ Management??

  19. Bleed and Infection control • Vit K • FFP • Td • Ancef • Cocktail of shame

  20. CT Head • No acute injury • Chronic ischemic changes • Atrophic temporal lobe • Lacune left thalamus • Old left and right cerebellar infarcts

  21. CT Scan of Facial Bones • Left eye blowout # • Lt zygoma# • Very displaced bilateral maxillary wall# • Ruptured left globe with air in the orbits • Masserated left lateral and medial recti muscles • Bilateral nasal bones #

  22. Radiologic Evaluation Continued • CT chest: Small lung contusions bilaterally, otherwise normal • CT abdomen normal • CT C-spine normal

  23. Now What?

  24. Plastics • Sutured some of the facial lacerations • Other lacerations not amenable to suturing because of significant progression of swelling • “Needs ORIF in a few days when stabilized”

  25. Optho • Exploration of the left globe the same night • Left lateral canthotomy • No rupture found

  26. Trauma • Suggested admission to ICU • Will follow

  27. Course in Hospital

  28. PTD#1 • Continued bleeding from the mouth overnight, 1-2 L of blood suctioned • Transfused 6U PRBC and 12U FFP • Continued bleeding despite normalization of coagulation • Sedated on Propafol, morphine throughout GCS: E* V1T M6

  29. PTD#1 Continued • Face swollen 2 times its original size • BP 150-190 systolic, no significant tachy • ? Options to control bleeding?

  30. PTD#1 Continued • Nipride drip started to control BP • Sent to angio to embolize the bleeding vessels: Sphenopalatine arteries embolized bilaterally

  31. PTD#1 Continued • In the angio-suite BP dropped to 50 systolic and remained there for 15-20 minutes • Finally restored after 1 dose of neosynephrine

  32. PTD#2 • Plastics requests clearance of C-spine prior to OR • Fluids: 13L positive balance • Diuresed for CHF on CXR • Pt taken for tracheostomy

  33. Neurologic Exam • GCS 3T  5T (V1T, E3, M1) when off sedation • Bilateral flaccid paralysis • No lateral movement of the eyelids • ?Obeying commands to open and close the eyes.

  34. ? DDx for Neurologic Deterioration?

  35. DDx • Brainstem: pontine infarction –locked in state (secondary to athrosclerosis, hypotention, or arterial injury to the neck) • Spinal cord: compression, transverse myelitis • Peripheral nerves: guillain-barre syndrome, critical illness polyneuropathy

  36. DDx cont.. • Neuromuscular junction: delayed neuromuscular blockade, myesthenia gravis • Skeletal muscles: hyperkalemia, hypophosphatemia or hypomagnesemia, critical illness myopathy, acute alcoholic myopathy

  37. Workup • Normal CBC, electrolytes, Ca, Mg, PO4, LFT; stable BUN/ Cr • MRI of head: new large pontine infarction • CTA neck: bilateral athrosclerotic stenosis is ICA, Normal Rt vertebral artery and opacification of Lt vertebral artery from C3 up

  38. Vascular trauma in the neck

  39. Intro • BVI of neck are potentially the most devastating and underdiagnosed injuries seen following stabilization of a polytrauma patient • Commonly associated with other confounding injuries

  40. Associated Injuries • Closed head injuries • Facial fractures • Basal skull fractures through carotid foramen • Upper thoracic fractures • C-spine injuries

  41. Mechanism of Injury • MVC (most common) • Any injury with lateral hyperflexion/ hyperextention of the neck resulting in traction or compression of the arteries of the neck • May be associated with relatively minor trauma

  42. Incidence • No large population based studies are available • Several large level 1 trauma centers report detection rate <1% of all blunt trauma patients

  43. Incidence • Increasing incidence seen in recent years because of more aggressive investigation attempts. • 80% ICA;20% vertebral artery

  44. Diagnostic Modalities • Angiogram: gold standard • CTA: improving technology/ sensitivity rates described >90% • MRA: may define other associated injuries and more detailed description of resultant and concominant brain pathology

  45. Diagnostic Uncertainty • Variability of presentation • Cost and invasiveness of diagnostic modalities • Who to screen given the low incidence

  46. Proposed indication for screening • Carotid canal fractures • Neck hematomas • Neurologic deficits not explained by CT head Journal of trauma vol 45(6) December 1998. 997-1004

  47. Theraputic Modalities • Antiplatelet therapies: ASA, Plavix • Heprinization: early vs. delayed • Coumadin short vs. long term • Surgical repair: open vs. endovascular techniques

  48. Theraputic Uncertainties • No randomized trials; Only retrospective studies available • No significant difference in morbidities and in hospital mortality (all cause) when antiplatelet therapies compared to anticoagulation.

  49. Theraputic Uncertainties Continued • No difference in early vs late heprinization • Significant difference between treated and untreated group • Small number of patients • Retrospective evaluations

  50. Theraputic Uncertainties Continued • No randomization • Single centers • Untreated group more severe injuries precluding them from anticoagulation Vol 2, 2004. Cochraine review.

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