Case 4

Patient: 34-year-old man.

Incident: While riding an MPWC, he collided with another MPWC. Their respective speeds were unknown.

Injuries: Immediate loss of consciousness; mouth-to-mouth resuscitation was carried out by friends for 5-10 minutes on a nearby boat. Intubated before arrival at RNSH. He had a Glasgow Coma Scale score of 6 on arrival at RNSH, left pupil larger than the right (neither reacting to light), deep forehead laceration with brain matter showing, full-thickness lip laceration, bilateral periorbital haematomas, continuous blood loss from both ears and nostrils, subcutaneous emphysema over the left anterior chest and a deep left-knee laceration.

Investigations: X-rays of the chest, lateral cervical spine and pelvis were normal. Computed tomography scan of the head showed a linear transverse frontal fracture, frontal cerebral contusions, right frontal epidural haematoma, tentorial subdural haemorrhage and scattered small contusions. Multiple facial fractures were also present. Abdominal computed tomography scan was normal.

Management: Sedation, paralysis and hyperventilation; debridement of frontal head injury and craniectomy; drainage of epidural haematoma; insertion of a subdural catheter; and debridement and suturing of facial and knee wounds.

Outcome: After 16 days in both intensive care and a ward, he was transferred to a rehabilitation unit in a persistent vegetative state and dependent on a ventilator. He was blind and he had developed pneumonia and pulmonary emboli. Three months after the accident, a computed tomography scan showed post-traumatic encephalomalacia and marked hydrocephalus. Nine months after the accident, he could open his eyes in response to speech and had a flexion response to pain.