Case of the Month February 2015

Complications of Auto versus Pedestrian

Submitted by Jonathan Frankel, MD, and Thomas J. Learch, MD.

HPI

A 63-year-old female with a history of arthritis and bilateral hip replacements. While crossing the street she was struck by a vehicle traveling 35 mph.  She denied any loss of consciousness. Spidering was noted in the passenger side window. She was found to have bilateral lower extremity and right upper extremity deformities with bilateral thigh ecchymosis.

Physical Exam

  • Neuro
    • GCS 14 (E3, V5, M6)
  • Head
  • Face
    • 1cm Right forehead laceration
  • Abdomen/Pelvis
    • Bilateral hip tender to palpation
  • Back
    • Right scapular abrasion
  • Extremities
    • Right humerus deformity, Bilateral tib/fib deformities. Contusions to Bilateral thighs.
    • Left tib fib ulcer

Radiographs of Chest and Extremities

She immediately received radiographs of her chest and extremities.

For larger images, please click on Auto-Ped 1   Auto-Ped 2 , Auto-Ped 3   Auto-Ped 4 and Auto-Ped 5

Radiograph Findings

  • Pelvis
    • Displaced right ilium
  • Chest
    • Displaced fractures of the right posterior 4th through 6th ribs
    • Nondisplaced fracture of the right scapula extending to the glenoid
  • Right humerus
    • Comminuted and displaced fracture of the mid humeral diaphysis
    • Nondisplaced fracture of the right scapula
  • Bilateral lower extremity
    • Comminuted fractures of the right tibia and fibula at the mid diaphysis
    • Nondisplaced fractures of the right distal tibial diaphysis
    • Comminuted and displaced fractures of the proximal tibia and fibular diaphyses on the left.

CT Brain

For a larger image, please click on Auto-Ped 6 .

CT Brain Results

  • Acute/hyperacute left frontoparietal 9 mm subdural hematoma with effacement of left-sided sulci, mild flattening of left lateral ventricle and 2 mm midline shift
  • Right parietal extracranial soft tissue swelling/hematoma

Management

  • Follow up CT Brain demonstrated decreasing subdural hematoma, patient was managed conservatively.
  • A sudden change in mental status on the second day of admission demonstrated more somnolence and she was not following commands, not opening eyes.
  • Narcane did not improve her exam
  • Patient was intubated and taken for emergent subdural hematoma evacuation.
  • Hematocrit was dropping, concern for pelvic or long bone injury complication.
  • Orthopedics took patient to operating room for emergent external fixation of bilateral lower extremity fractures following craniotomy.  

Post-Operative CT Brain

For larger images, please click on Auto-Ped 7 and Auto-Ped 8 .

Post-Operative CT Brain Results

  • Status post subdural hematoma evacuation, decreased subdural blood products with expected post operative changes
  • External ventricular drain in place, stable ventricles

Management 

  • GCS 5T (E1V1TM3)
  • Patient’s neurologic status is unchanged despite subdural hematoma evacuation, will not open eyes to voice or pain
  • Moves all extremities
  • EEG is abnormal

What is the next step in management? 

  • Repeat CT Brain to reevaluate subdural hematoma
  • Cerebral angiogram
  • MRI Brain
  • Watchful waiting

 

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