Open craniocerebral trauma in a patient at work: A case report

1 Introduction

In our modern industrialised environment craniocerebral injuries and their consequences constitute an important factor of mortality and morbidity among the population. The incidence of traumatic brain injuries (TBIs) in the European Union annually leads to 1.5 million hospitalisations and 57,000 deaths associated with post-traumatic brain injury [1]. TBI accounts for about 30% of all injury deaths [2]. Craniocerebral trauma through accidents at work accounts for about 4.4% of all craniocerebral trauma, of which 7.3% are serious injuries.

One third of all the cases of craniocerebral injuries in the United States occurred in seven industries: logging, roofing, garbage collecting, trucking, farming and construction [3]. Craniocerebral injuries are more common in men [4].

Avoiding the consequences of a craniocerebral injury in the workpalce, especially where employees are engaging in activities that could result in an injury, requires taking all precautions and using appropriate safety equipment such as protective helmets.

This may possibly reduce the effects of the initial injury and could have a considerable positive impact on the prognosis.

The application of appropriate diagnostic measures and surgery techniques, even in severe craniocerebral injuries in the workplace, gives a positive outcome [4–6]. The following study presents the case of a 20-year old male who suffered an open craniocerebral injury in the work place.

2 Case Report

The Basic Medical Rescue Team from Bielsko-Biała was dispatched to a 20-year old patient who had suffered an injury. The reason for calling the rescue services was a head injury the employee had sustained while operating a snow cannon. The public safety answering point (PSAP) dispatcher obtained the information that the injury was the result of a metal element from a hydrant which was supposed to be connected to the snow cannon, hitting the patient forcefully on the head. Due to the distance and difficult road conditions the arrival at the incident was performed under code 1 – rescue action mode. After arriving and safely parking the ambulance, the medical rescuers began carrying out the medical rescue activities. The injured person had earlier been examined and secured on a spinal board by the Mountain Search and Rescue team within their scope of providing qualified first aid. After transporting the injured person into the heated ambulance the rescuers began the preliminary assessment according to the ITLS (International Trauma Life Support) scheme. The patient was slightly drowsy, and in their assessment of the level of consciousness performed using the scale

AVPU – V, he reacted to voice. In addition the airways were patent and the heart rate was easily palpable at the carotid artery and at the radial artery at 70 beats per minute. The commander of the team decided to introduce oxygen therapy using a face mask with a flow of 15 l / min.

Due to the loss of consciousness directly after the head injury the decision was taken to perform a rapid trauma assessment. The head examination revealed an injury of the right temporal area with a depressed fracture of the skull bones and a little bleeding which was managed using a protective dressing. Continuation of the trauma assessment of the other parts of the body did not demonstrate other injuries. On auscultation the vesicular murmur was symmetrical and the heart sounds were clear and loud with a frequency of 70 beats/min. The pupils were isocoric, symmetrical, and were sluggish in reacting to light. The oxygen saturation was 96 %, the oxygen therapy was continued. Due to the low blood pressure (90/60 mmHg) the team commander made the decision to begin fluid therapy. Two peripheral venous catheters were inserted and 2×500 ml of 0,9 % Na Cl was administered.

The SAMPLE survey provided a lot of valuable information: the patient had no allergies, did not suffer from any diseases, had had his last meal an hour earlier and the head injury was caused by a metal part from a hydrant which hit his head under high pressure. At the time of the accident he was not wearing any protective headgear. The difficult atmospheric conditions made it impossible to call the Air Rescue Services. The patient had to be quickly transported to a hospital possessing a neurosurgical department. The commander made the decision to urgently transport the patient to the Independent Provincial Hospital in Bielsko-Biala. During the transportation the patient’s life parameters were monitored, the oxygen therapy and fluid therapy were continued, and his thermal comfort was ensured. The injured man was admitted to the Neurosurgical Department of the Provincial Hospital in Bielsko-Biala for the surgical treatment of an open craniocerebral injury. Within the scope of the admission room activities the patient was subjected to diagnostic imaging (a computerised tomography (CT) scan of the head and cervical spine and an ultrasonogram (USG) of the abdominal cavity).

The CT scan of the head revealed a multi-fragmented fracture of the temporal squama with partial depression and partial elevation of fractured bone fragments and a hemorrhagic contusion in the right frontal area directly next to the injury (Fig. 1).

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Fig. 1

Computed tomography image after the injury.

The CT examination of the cervical spine and the USG of the abdominal cavity did not show any pathological changes. Laboratory examinations demonstrated a serum glucose level of 173 mg/dl and a leukocyte count of 18,500. The remaining results of the laboratory examinations showed no other deviations. The patient was qualified for urgent surgical treatment. On admission the patient was conscious, evaluated as 12 points (Eye (E) 3Verbal (V) 3 Movements (M) 6) on the Glasgow Coma Scale (GCS)). His pupils were isocoric and of correct width and reactivity. His systemic pressure was 150/90 mm Hg and heart rate 78/ minute. The neurological examination did not show any motor impairment. In the right temporal area a local bleeding skin wound of multi-angle shape was found, with the presence of necrotic brain tissue coming out of the wound and with the presence of bone chips.

The patient was urgently operated on. A right-sided temporal craniectomy was performed and the multi-fragmented fracture of the temporal squama was debrided with the removal of the loose bone fragments. The intracerebral hematoma was evacuated. A duraplasty was performed using a neuro-patch type material and the skin wound was debrided. The patient was not awoken from the anesthesia. After the surgery, pharmacological sedation was maintained and the patient was transferred to the intensive care unit for further treatment. The treatment plan included polymodal sedation, anti-edema therapy, antihemorrhagic treatment and antibiotic therapy. The water-electrolyte and acid-base imbalances were aggressively corrected. Due to the low values of arterial pressure, the circulatory system was supported by a noradrenaline infusion. The first control CT scan of the head revealed the condition after the removal of the intracerebral hematoma with the presence of a hemorrhagic imbibition in the right temporal area. The ventricular system was axially aligned and not displaced (Fig. 2).

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Fig. 2

First computed tomography image after first operation.

The second control CT scan (Fig. 3) revealed the intensification of edematous lesions of the brain and radiological symptoms of increasing intracranial compression (flattening of the gyri (ridges) and narrowing of the sulci (grooves) at the convexity, a mass effect in the form of compression and displacement of the supratentorial ventricular system to the left and the compression of basal cisterns).

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Fig. 3

Second computed tomography image after first operation.

The patient was qualified for surgery to enlarge the osseous and meningeal decompression. The surgery was performed on the fourth day after the craniocerebral injury. The second surgery resulted in a subsidence of the edematous lesions of the brain and this was confirmed by a control CT scan of the head (Fig. 4).

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Fig. 4

Computed tomography image after second operation.

The sedative drugs were slowly withdrawn. On the eighth day after the injury the patient regained consciousness and he fulfilled oral commands. The improvement in the efficiency of his respiratory system meant that the mechanical ventilation could cease and the patient was extubated. After awakening the patient demonstrated left-side paralysis which subsided over the next few days. When the patient was once again transferred back to the neurosurgical department the motor impairment had completely subsided. After continuing the conservative treatment and rehabilitation the patient was discharged from hospital and returned home. He was conscious, fully verbally communicative, self-reliant, and had scored 15 points on the GCS (E4V5M6) assessment scale. After outpatient observation he was qualified for cranioplasty.

Based on an analysis of 301 hospitalisations related to TBI as a result of an accident at work, Heyer and Franklin determined that the patients’ average age was 36 years (14–75 years) and the cause of most injuries was falls (48.5%), accidents due to impact from a moving object (26%) or motor vehicle accidents (18.3%). High accident risk occurs during running, repairing roofs and in the transport, agriculture and construction industries [3].

In the period from January 2010 to March 2020, 1,165 patients with craniocerebral injuries were operated on at the Department of Neurosurgery in Bielsko-Biała, including 3 injuries as a result of an accident at work, which constitutes 0.25% of all operated patients. All patients are male. The average age of the patients was 43 years (the range from 20 to 64 years). The causes of the injuries were being hit by a metal hydrant (described in this study), being crushed by the plunger of a hydraulic press and falling off an asphalt machine. Two patients had a very good result, one patient died.

The severity of craniocerebral trauma is determined using the GCS (14–15 mild trauma, 9–13 medium trauma and ≤8 severe trauma). 56–60% of patients, initially rated at ≤8 GCS, also have multiple organ trauma (of one or more systems). 25% of patients require surgical treatment [5].

Trauma damage can cause primary destruction to the integumentary system (cuts, wounds, lacerations, muscle and tendon injuries), to bones (linear and multiple-fragmented fractures) and to nerve structures (direct damage, intra-cerebral hematomas, peri-cerebral hematomas).

Compound elevated fracture of the skull is a rare type of fracture which is the consequence of a high velocity tangential impact to the skull vault. Borkar et al. described a clinical series of three patients [7] and Gupta et al. described eight patients. Most patients of our series were managed by performing decompressive craniectomies [8].

The effects of a craniocerebral injury may have the characteristics of a primary injury occurring immediately as a result of the action of the damaging factor and of a secondary injury resulting from hypoxia, the release of endogenous amino acids, and the production of pro-inflammatory substances and free radicals [2].

These injuries can only be guarded against by the use of protective headgear when performing work that could generate the risk of craniocerebral trauma.

Kim et al. studied the effects of using protective helmets in TBIs caused by falls from heights at work and demonstrated the effectiveness of protective headgear against the effects of brain injuries caused by falls of up to four metres [6].

The examples of good practices in preventing craniocerebral injuries among employees include a wider use of personal protective equipment, including head protection. This may possibly reduce the effects of the initial injury and could have a considerable positive impact on the prognosis [9].

In the case described above, the employee did not have a protective helmet. The general health and safety regulations stipulate that it is absolutely required to use helmets when working at the height of more than 2 m above the external ground or floor level.

In Poland, the provision results from the Regulation of the Minister of Labor and Social Policy of September 26, 1997 on general provisions on health and safety at work (uniform text: Journal of Laws of 2003 No. 169, item 1650 as amended). Annex 2 to the above ordinance also requires the use of head protection in the event of risks caused by falls from a height, impact, explosion, shock, crushing and electrical hazards.

Having consulted the employees or their representatives and refering to an occupational risk assessment the employer decides on which work in a given workplace and in which places of the plant the protective helmet should be used by the employee. (Act of June 26, 1974 – Labor Code- uniform text Journal of Laws of 2014, No 0, item 1502 as amended). The recommendation is also quoted in the EU Directive of 1989/391/EU.

The occupational risk assessment did not take into account the application of this protection measure to the activity performed by the employee. Due to the specificity of the device, when connecting the snow cannon, the employee used the personal protective equipment including protective gloves, appropriate clothing and footwear. Reducing the effects of secondary brain damage is influenced by the prehospital therapy offered and the subsequent appropriate hospital treatment.

Pakulski et al. proposed an algorithm for proceeding with a patient after a craniocerebral injury in the prehospital period, point out that implementing an appropriate therapeutic procedure at the site of the incident considerably lowers the mortality rate [10]. The rescue procedure comes down to ensuring proper airway patency, maintaining oxygen saturation above 95% and CO2 end-expiratory pressure at 35–45 mmHg.

The medium systolic pressure should be maintained at a minimum of 90 mmHg and fluid therapy given using a balanced crystalloid solution (a multi-electrolyte fluid) as well as an infusion of catecholamines (noradrenaline). For patients in a severe condition 15% Mannitol should be administered intravenously.

When the hospital is only a short distance away (< 10 min), the “load and go” rule applies. Hospital treatment should include rapid diagnostics (computed tomography, laboratory tests) and qualification for surgical treatment, including wound debridement, removal of tissue affected by necrosis and, in the case of multi-fragmented bone fractures, removal of the depressed bone fragments, dressing of brain contusions, and peri-cerebral hematomas and restoration of the integrity of the integuments in open injuries, in order to assure protection against liquorrhea and infectious complications. The use of appropriate diagnostic options and surgery techniques, even in severe craniocerebral injuries in the workplace, gives a good final result [10–13].

4 Conclusion

The routine use of head protection during all activities carrying a risk of a craniocerebral injury should be obligatory. Rapid implementation of the appropriate treatment procedure in a patient after a craniocerebral injury in the prehospital and in-hospital period means that the effects of secondary damages are avoided or reduced, which may result in a good treatment outcome.

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.