Open Head and Maxillofacial Trauma | A Complex Case Report

OPEN HEAD AND MAXILLOFACIAL TRAUMA, CASE REPORT FROM A ROAD ACCIDENT IN ITALY

Author: Dr. Stefano Barbadori, Tuscany Region Rescue Helicopter Director Pegaso 2 operational base at Grosseto

CASE REPORT: Summer 2020, Italy. Reported dynamic: road accident, handbike versus truck collision. Man, unconscious.

At 16:57 the Pegaso 2 helicopter rescue service from Grosseto is activated for a road trauma on road XYZ in the Province of Siena. The Regional Operations Center reports an accident involving a cyclist and a heavy truck. No detailed medical information on the clinical condition of the injured is available, as no rescue unit has yet arrived at the scene.

At 16:59 a helicopter takes off from Grosseto with an estimated arrival time at the accident scene of approximately 20 minutes. The crew consists of a commander and first officer, an HHO (Helicopter Hoist Operations ) technician, a mountain rescue technician, an emergency doctor, and a nurse.

At 17:25 the helicopter is hovering above the accident site. A few cars, a truck and 1 or 2 ambulances, partially concealed by the trees,  are spotted from the helicopter. Considering the characteristics of the road and the presence of numerous people, the pilot suggests landing at an approximately 50 meter-distance from the scene. The distance from the landing point to the accident site is easily covered on foot. Along the last asphalt stretch the rescue team is approached by some of the numerous bystanders who disclose the identity of the patient and the dynamic of the event: a bike-truck crash during an amateur cycling race.

a) Scenario assessment

– Safety: numerous parked vehicles, well laid out, no risk of other vehicles invading the scene.

b) Health assessment

– The patient is lying motionless on the ground. Immobilization devices have already been positioned by the emergency doctor, who had previously arrived by medical car, and by the rescue volunteers. The patient is being ventilated with a self-expanding balloon with a supraglottic device.

c) ABCD (Airway, Breathing, Circulation, Disability) Reassessment

– A: airway managed with laryngeal mask

– B: OPACS: no alterations

• – O = observe the symmetry and correct expansion of the chest
• – P = palpate the chest for signs of broken or bruised ribs or subcutaneous emphysema
• – A = auscultate the chest to check if the lung apices and bases are properly ventilated
• – C = count respiratory rate for brady or tachypnoea
• – S = saturimetry (remembering that the patient is already receiving oxygen therapy)

– C: Normal cardio-circulatory parameters: BP 130/80; HR 90′.

– D: AVPU (Alert, Verbal, Pain, Unresponsive) scale =U. GCS (Glasgow Coma Scale) = 3

d) Cranio-caudal Assessment

– Extensive right fronto-parietal wound with 4 cm diameter bone fragment dislocation and partial pitting

– Diffuse maxillofacial swelling

– Rest of the body: no obvious signs of traumatic injuries to the neck, chest, abdomen, pelvis and stumps of both lower limbs that had been amputated a long time ago for a previous severe polytrauma.

The patient is transferred to the ambulance for ease of management, and the maneuvres are continued as necessary:

– Cannulation of 2 peripheral veins of appropriate caliber for a safe venous route

– Volemic filling (250 cc of isotonic saline solution)

– Orotracheal intubation after sedation-analgesia (Ketamine, Fentanyl, Benzodiazepine)

– Mechanical ventilation with mechanical ventilator in ASV: FiO2 60%, PEEP of 5 mmH2O, TV of 500 ml, R.R.  15 breaths/minute, M.V. 5.8 Lt/min. with good response: Sat.HbO2= 98%, EtCO2= 34 mmHg.

– Application of gauze packs in the oral cavity to reduce bleeding

– Multi-parameter monitoring

– Repositioning of the cranial bone fragment from the encephalic structures, aspiration of blood material from the traumatic breach and positioning  to reduce the opening of the overlying bony and soft structures

– Craniofacial packing with immobilization and maximum compression of anatomical structures

– eFAST examination to exclude the presence of free blood in the abdominal cavity and pericardium, and a hypertensive pneumothorax.

The rescue operation on the scene lasts 28 minutes.

At 17:47 the helicopter takes off with destination Santa Maria alle Scotte Hospital in Siena after notifying the Regional Helicopter Operations Centre and the competent local centre (C.O. Siena Grosseto). The estimated flight time is approximately 20 minutes. No complications during the flight, the patient continues to be ventilated in ASV mode with the above parameters.

At 18:04 the helicopter lands at the Policlinico Santa Maria alle Scotte helipad in Siena and the patient is transferred by ambulance to the Trauma Center of the same hospital in about 3 minutes.

When the patient arrives at the Trauma Center all the specialists (Intensivist/Emergency Doctor, Radiologist, Neurosurgeon, Emergency Surgeon, Transfusionist), pre-alerted by the Regional Operations Center, are present.

The case is described in terms of event dynamic, patient condition and treatment provided.

The patient is handed over to the multidisciplinary team of the Trauma Center of Siena.