Case presentation
An adult male patient in his 30s, with no medical history was admitted to a local hospital after sustaining a fall off an 8 m high scaffold. Initial clinical assessment revealed an unconscious patient with a GCS of 8/15 (eye opening: 1; verbal response: 2; motor response: 5), pupils equal and reactive to light, a pulse of 107 bpm, a blood pressure of 100/60 mm Hg, a respiration rate of 24cpm, with an O2 saturation of 87% on ambient air. The patient was intubated and a full-body CT scan was performed revealing a 4 mm frontoparietal subdural hematoma, an undisplaced fracture of the right frontal bone with a subgaleal hematoma and an ipsilateral eyelid edema, a right hemopneumothorax along with pulmonary contusion and ipsilateral flail chest as well as a subcutaneous emphysema spreading to the neck. No injuries were found in the abdomen. An X-ray of the upper right limb revealed a fractured humerus stabilized using a brace.
The hemopneumothorax was drained but the patient developed shortly afterwards a hypotension of 80/50 mm Hg refractory to volume expansion using isotonic saline. A femoral central venous line was taken and norepinephrine was initiated. A FAST (Focused Assessment with Sonography for Trauma) examination was performed and came back normal. The patient was referred to Mohammed VI University hospital for specialized management.
The patient was admitted within an hour and a half from the causing accident. At admission, our assessment found an unconscious patient, intubated and ventilated, anisocoric, with a blood pressure of 95/50 mm Hg under norepinephrine, a heartbeat of 120 bpm, a respiration rate of 26 cpm and a O2 saturation of 95% under mechanical ventilation. A continuous infusion of norepinephrine was maintained through a subclavicular central venous line, and blood pressure was invasively monitored using an arterial line.
We performed a full-body enhanced CT scan revealing the same head injuries as the initial CT along with a subarachnoid hemorrhaging and a cerebral edema without a mass effect. In the thorax, it revealed a bilateral pneumothorax more prominent on the left, a right hemothorax, a pulmonary contusion in the superior left lobe as well as the lower right lobe with multiple pneumatocele, a reduced caliber of the mediastinal great vessels, and a chest tube placed in the left pleural cavity (figure 1). Abdominal images revealed a Grade 1 liver trauma in the fifth and sixth segments, a Grade II right renal trauma, and a peritoneal effusion. The bone window revealed fractures through the lateral curvatures of ribs 3 to 12 on the right.
Laboratory tests revealed a hemoglobin at 6,4 g/dL, a 19% hematocrit, a platelet count of 138 000, fibrinogen levels at 0,8 g/L, a 46% prothrombin ratio, an aPTT (activated partial thromboplastin time) of 1.02 s, HS Troponin levels at 1932 ng/L. The patient’s blood type was O positive, and we transfused 3 units of packed red blood cells, 2 units of Fresh Frozen Plasma (FFP), and 5 units of platelet concentrate.
There was no emergency surgical procedure needed at the time being (in concertation with the surgical team).
Given the sustained hemodynamic shock in spite of volume expansion and the use of norepinephrine, and in light of the high suspicion of myocardial contusion (given the blunt chest trauma, the nature of the chest injuries, and the sustained hemodynamic instability along with high troponin levels), we decided to initiated continuous dobutamine infusion as well.
A follow-up physical examination revealed deviated heart sounds to the right, subsequently an in-bed plain Chest X-ray (CXR) was performed revealing a right sided heart (figure 2), confirmed by a transthoracic echocardiography (TTE).