Israeli Paramedics Association
2
The Israeli Emergency Medical Journal
Chief Editor - Paramedic Neomi Zvi
Case Report:
Penetrating Head Injury
by
Michael Albertal, MD / Paramedic Neomi Zvi
One of those hot days of the summer vacation in Israel.
9 years old , Yaron , went to visit his father at the construction site.
But Yaron's father was not there
at the time . and Yaron climbed
the roof's scaffolding of the
unfinished building.
All of a sudden , Yaron lost his
balance and fell from heights of
8 meters , on the concrete surface.
A lot of steel rods (cast-iron pole)
were build in the concrete surface.
One has penetrated Yaron's skull -
entered the through the Frontal bone
and exit through the Occipital.
Yaron was skewered by the 0.4 inch steel-rod to the floor, with his face down.
He lost consciousness , and start to convulse....
The workers that were witness to Yaron injury , called 101 (Israeli EMS Emergency
Number) , and support Yaron's body while waiting.
First on scene , EMT-B , Shai Evron. He reported the Dispatch Center and was
trying to make sure that Yaron's medical state won't get worsed due and during
the complicated extrication. The equipment that the FireFighters had - was not
suitable. Yaron's head was only 2.5 inches from the ground. The workers
somehow managed to get the right steel saw and helped with the extrication.
MICU's team arrived from the other city.
Paramedic Gil Latman have found Yaron severely convulsing , Closter-Apneostic
changing breath pattern , Heart Rate about 50/min , Sinus Bradycardia ,
BP - was in the "sky" as expected. (Cushing Triad)
Yaron was still skewered to the ground and the extrication efforts advanced
slowly , step by step. Every mm of movment can cause more damage to Yaron's
Brain..... The workers were still supporting Yaron's body , and the head/neck was
'fixed' anyway...
Paramedic Gil Latman ordered for Assisting Ventilation with BVM (Bag-Valve-Mask)
and Oxygen , till an IV line will achieved for sedation and Anti-Convulsions drugs.
Only high doses of Diazepam IV could stopped the convultions , for a while anyway.
Gil decided to Intubate , despite the almost impossible position. On his second attempt
Gil successfully intubated Yaron. Bag-Tube Ventilation is now on.
Finaly Yaron was extricated , fixed to a Spinal Board - while his head
is turning to the right - due to the cast-iron pole that is crossing his skull.
After going down from the roof , Yaron was transported to Rambam Trauma Center .
in Haifa , about 20 minutes drive from the scene.
Yaron was brought to the ER - Intubated , Ventilated , Hemodynamically stable,
Round , Medium Dilatation , Unresponsive Pupils.
Moving 4 extremities , more intentionally on the right and Decortication on the left.
Initial CT scans demonstrated severe Brain Edema at the posterior parts , a lots of
small bleedings and bone's fragments s were spread in the brainstem...
Special technic was used in the OR to pull the steel rod out of Yaron's brain......
The neurosurgeons made some debridement of the wounds , and left a cathether to
monitor the ICP (Intra Cranial Pressure).
A second CT scans have shown that the steel-rod were passing very close to the
Midline , and 'slipped over' the Brainstem...
Yaron was transported from the OR to the (PICU) Pediatric Intensive Care Unit
On his first days at the PICU , Yaron was under Pentotal Anaesthesia and got an
intensive treatment to decreased the ICP (Manitol and Diuretics).
After few days of Anaesthesis , Clinical and Radiological evidence have pointed
a significant decrease of the ICP.
The Anaesthesia was stopped and Yaron started to woke up gradually .
The severe Meningitis was next to be challange , and Yaron made it.
After few more days , Yaron left the PICU , for continuing treatment and
Rehabilitation .
Almost a year later , Yaron was back to his class , studying like any other normal kid ,
except his Left Hemiparesis.
Both , Yaron & Paramedic Gil were very excited to see each other , at the special
ceremony that was arranged for them.
Summary:
Yaron's chances of survival were slim. But , proper decisions , professional treatment
and high skills of the EMT-B , The Paramedic , the Trauma team and all the other
medical staff - gave Yaron the chance to live.
That Exactly what the CHAIN OF SURVIVAL is all about !
Urgent - The Israeli Emergency Meicine Journal , Volum No 2
Paramedic Neomi Zvi - May 2000