Traumatic Subdural Hematoma and Intraparenchymal Contusion after a Firework Blast Injury-Juniper publishers
JUNIPER PUBLISHERS-OPEN ACCESS JOURNAL OF HEAD NECK & SPINE SURGERY
Introduction
Firework displays are a frequently encountered and
integral part of summertime holiday celebrations in the United States,
although they do carry significant risk, especially in the pediatric
population. Firework-related injuries comprise a small, yet significant,
source of pediatric injury [1]. Since 1990, more than 5000 children
were treated for consumer firework-related injuries in emergency rooms
across the United States on an annual basis [2]. In 2014 alone, 10,500
firework-related injuries required hospital treatment [3]. While
orthopedic and burn injuries to the hands compose the majority of these
injuries, 22.0% of firework-related injuries involve the head or neck
[2]. Furthermore, a significant percentage of these injuries are
suffered by bystanders [3]. A small fraction of these injuries require
hospitalization, and even fewer require operative intervention [4,5].
Pediatric brain injury due to projectile or explosive
weapons in both civilian and military zones is well known [6-8]. While
head injury caused by fireworks comprises approximately a fourth of all
fireworks injury in children, there has not yet been a report in the
literature of a firework impact causing an intracranial hemorrhage, much
less an injury requiringemergency neurosurgical intervention. Herein we
report a
6-year-old male bystander who suffered a consumer firework-related blast
injury, requiring emergent hemicraniectomy for evacuation of a subdural
caused by the fireworks impact
Case Report
History and Examination
A 6-year-old boy with no significant past medical
history was at a neighborhood party celebrating Independence Day. The
boy was a bystander in a crowd when a large firework misfired and hit
the boy in the right temple. Per report, the firework exploded on or
around the time of impact. The boy reportedly lost consciousness briefly
and was then transported to our institution
On initial presentation, the patient had a Glasgow
Coma Score (GCS) of 14 with confusion regarding the year and his
location, in addition to left lower extremity weakness. He had a 5 cm
burn over his right temple with surrounding facial edema. Computed
Tomography (CT) of the head demonstrated a 9mm mixed-density right
convexity subdural hematoma with 11 mm of midline shift (Figure 1). No
skull fracture was identified(Figure 2). While in the trauma bay, he had
a steady decline in
consciousness. Due to the large subdural seen on imaging and
concordant worsening exam findings, the decision was made
to proceed with surgical intervention for evacuation of the
hematoma (Figure 3).
Operation
A right-sided front temporoparietal hemicraniectomy with
evacuation of a significant subdural hematoma was performed.
A temporal parenchymal contusion was noted as the likely
culprit of the subdural blood. Due to substantial cerebral edema,
the bone flap was not immediately replaced. A right frontalintraparenchymal pressure monitor was placed, and he was
taken to the Pediatric Intensive Care Unit post-operatively. A
post-operative head CT was performed, showing satisfactory
evacuation of subdural hematoma and markedly improved
midline shift (Figure 4).
Post-operative Course
His post-operative course was uneventful. Intracranial
pressure remained within normal limits, and he briskly
followed commands. On the first day following surgery, the
intraparenchymal pressure monitoring device was removed, and
he was extubated. He progressed well and was discharged on
post-operative day 5. He returned 1 month after his initial injury
for autologous cranioplasty and tolerated the procedure well
without complications. At 5 months follow-up, he had returned
to school with minor emotional outbursts and attention issues
that were not present prior to injury.
Discussion
Fireworks, while a common part of many holiday celebrations
in the United States, are an important etiology of pediatric injury.
All common consumer fireworks have been known to cause
injury, including death, incurring significant medical expenses
[9]. However, significant firework-related neurological injury
has not been previously reported in the literature. In the case
discussed, we report a bystander child who incurred a serious
neurological traumatic brain injury secondary to an aerial
consumer firework used at a neighborhood firework display.
Due to the severe injury, the child underwent a major surgery for
evacuation of intracranial hematoma. Additionally, the patient
required multiple days in the intensive care unit, required repeat
admission for bone flap replacement, and had lasting cognitive
effects
Surprisingly, firework-related injuries to pediatric
bystanders is reported in 26% of all fireworks injury cases [4].
Greater than half of the reported cases include adult supervision,
demonstrating that even adult supervision does not necessarily
prevent these types of injuries [4]. Public education initiatives
about the dangers of fireworks have also failed to translate tomeaningful changes in rates of pediatric fireworks injury [10].
The American Academy of Pediatrics has advocated for abolition
of all consumer fireworks, encouraging attendance solely at
public fireworks displays [11]. Given that consumer fireworks
can cause pediatric head injury similar to that seen in weapon
projectile or blast injury, as demonstrated in the case presented,
this stance is reasonable [8].
Given the uncommon nature, traumatic brain injury
secondary to cerebral blast injury may be missed on initial
presentation, leading to a delay in diagnosis [12]. Recognition
that consumer fireworks can cause these severe and potentially
operative injuries is important in their overall treatment. The
case reported here highlights the first reported case of severe
traumatic brain injury and intracranial hemorrhage secondary
to a firework-related injury, denoting the need for increased
public knowledge of the danger of consumer fireworks
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