CASE 1
21 year old youngster after met with an RTA presented to tertiary orthopedic centre with fracture right leg. On admission he was alert and well oriented with gcs 15 and no neurological deficit noted. After 7 hrs of presentation his gcs dropped to 4. He was intubated and ventilated for airway protection and respiratory failure and referred to our centre for further management. On admission to our centre his bp 120/70, PR – 130/min, spo2 97% with 60% fio2 and 8 peep, temperature 38 deg, gcs 6 et/15, his chest xray showed bilateral infiltration. He had both bone compound fracture right lower limb for which thomas splint was applied outside. He was oliguric and had high coloured urine. Our initial suspicion was traumatic brain injury. As his ct brain was normal which doesn’t explain his low gcs he was done mri brain after stabilization which showed MULTIPLE SCATTERED PUNCTATE T2/FLAIR HYPERINTENSITIES in cerebral and cerebellar hemispheres. His cpk was 1050, cr was 1,his cardiac status was normal. He was resuscitated with iv fluids, iv augmentin, anti convulsants. He was done wound debridement after initial stabilisation on the day of admission. Next day he had worsening hypoxemia requiring fio2 60% and peep of 10. His cxr showed worsening infiltrations. His procalcitonin was low. ET c/s not grown organisms. His platelets decreased to 1.2 lakhs, He had petechial rashes over the trunk and left conjunctiva. On day 3 he had further drop in platelets to 1 lakh. On 4 th day had drop in CPK, Platelets started improving. His chest infiltrations were started clearing and able to wean ventilator support though his neurological status was showing non improvement. At 7 th day of hospitalisation he underwent orif tibia and surgical tracheostomy for ventilatory weaning. He was weaned from ventilator and shifted to step down unit in another couple of days. His neurological condition showing mild improvement of E2 m5 after 2 nd week. During further follow up his gcs improved to E3M6, started obeying at the end of 6 th week and he was weaned from trachestomy.
CASE 2
17 Yr old studying 12 th garad was sustained with femur fracture after met with an road traffic accident in the middle of the night. He had no loc/vomiting/ altered mental status. Initially he was admitted in tertiary ortho centre where he was initially treated. He had right femur mid shaft closed fracture. His ct abdomen showed grade 4 liver laceration, pernephric hematoma without hemoperitonium. He was resuscitated with I .v fluids, thomas splint and planned for surgical intervention for femur in the following day. When the patient was shifted to theatre after 8 hrs of presentation, found to have patient was in confused state and irritable. So the procedure was abandoned and ct brain was done which showed no neuroparenchymal abnormality. After that patient was referred to our tertiary care trauma centre for further management. On admission patient gcs was E2V2M5. Bp – 110/70, spo2 95%with 15 l 02, chest on auscultation showed bilateral crackles, he was tacyponic with respiratory rate of 32/min.blood gas analysis showed d po2 of 65mmhg, chest xray showed bilateral infiltration. He was intubated and ventilated. His echo cardiogram showed mild dilatation of right ventricle and normal lv function,he had oliguria and mild hematuria which improved after hydration. on admission his plat – 1.5 lakhs hb-10.8gms%,sgot-182u/l, sgpt-227 u/l, cr-0.7 ptt-32 sec, inr-1.46. next day his hb dropped to 7.9 gms%, haematocrit dropped to 24.3% and cpk – 2675 u/l, plat- 1,34000. cell. Thired day further drop in hb -7.5 gms%, plat-113000. Pt/inr-1, ptt-30 sec sgot-57 u/l, sgpt87u/l. t.bil1.18mgs%. He was requiring ventilaory support of 40%/ 6 peep. His po2 was improving. He was given 2 units of packed cells. On 4 th day patient has mild improvement in gcs and he was obeying simple commands. He was undergone ORIF FEMUR on 6 th day. Patient was given trial extubation as his gcs was E3V3M6 and he was protecting airway and oxygenation was improved. He was observed in stepdown unit before shifting to ward. On 13 th day patient was well oriented and gcs was 15/15, wound was healing well. Patient was discharged on 15 th day with good nurolgical status
MRI IMAGING .
multiple punctate hemorrges in the brain due to FES
SKIN PETECHIAE IMAGE