Author: Pierre Smit
Original presenter: Dr John Roos
Editor: Jo Park-Ross
At approximately 07H00 Ubuntu Aeromedical Service received a call on their rotor-wing platform for a young gentleman who had fallen from a height of approximately 5 meters. They were told that the incident had occurred at 06H00, and that the patient was standing on the trailer of a truck when it suddenly moved forward, causing him to fall off of the back end, head-first onto the concrete floor.
On arrival (09H55), they found the patient with typical signs of a severe traumatic brain injury: GCS of 4/15, Cheyne-Stokes breathing, signs of a basal skull fracture, a combination of Le Forte fractures and sluggishly reactive pupils which were equal in size. However, the patient also showed signs of severe decompensated hypovolaemic shock with a low blood pressure (63/51), pale, mottled, cold and clammy skin, and a delayed capillary refill time.
One would have expected to see a ‘Cushing’s response’ to the raised intracranial pressure consequent upon the severe traumatic brain injury (a well-perfused patient with hypertension and bradycardia). So, what happened here – how does one explain this paradoxical clinical presentation?
Shortly after the assessment of the patient was completed, the decision was made to intubate using rapid sequence intubation. However, during preparation for intubation, the patient deteriorated rapidly, went into cardiac arrest. After resuscitation attempts proved futile, the patient was declared dead on scene. The treating paramedic then decided to consult with the Continuous Quality Improvement department at Ubuntu Aeromedical Service, to gain clarity about the conflicting clinical signs in this mystifying “isolated” traumatic brain injury [about this extraordinarily complicated case].
An autopsy was later performed on the patient which revealed the following: confirmed base of skull fracture, intracerebral haemorrhage, pulmonary and cardiac contusions and massive bleeding within the thoracic cavity. Together, these post-mortem diagnoses paint a pretty grim picture. So the prevailing question is: what on earth happened in the chest cavity to cause such a catastrophic bleed? The answer might be a little surprising, as all that bleeding might have resulted from the traumatic failure of a single ligament, the ligamentum arteriosum.