Fireworks injury

A. AL MULLA, M. PURVA and A. BEHBEHANI* Mubarak Al Kabeer Hospital, Jabriya and *Faculty of Health Sciences, University of Kuwait, Kuwait

Introduction

Case Report

Discussion

References

We describe a case of a teenager sitting in a car, who was struck by a fireworks missile. The unusual presentation of a large wooden foreign body penetrating through the temporal bone and lodging in the brain is detailed. The management is discussed.

Fireworks have been used for centuries in various parts of the world for celebrations. Despite the dangers associated with them they have been used and misused by adults as well as children. In the absence of strict laws and legislation governing the manufacture of fireworks, tragic incidents continue to occur despite being preventable. We present here a case of a fireworks-induced head injury that resulted in the death of a young teenager.

A 13-year-old girl was admitted to Mubarak Al Kabeer Hospital in an unconscious state after being intubated in a small private hospital earlier. The girl was sitting in the backseat of a parked car when fireworks, set off outside the car shattered the glass of the rear window and hit her, following which she collapsed. There was an abrasion in the region of the right temple with tissue, similar in appearance to that of the brain, seen around the wound. Initially, she was rushed to a nearby hospital where she was intubated as she was deeply unconscious and then transferred to our hospital. No sedatives or muscle relaxants were used. On admission, her Glasgow coma score was found to be 4/15. Pupils were equal and reacting to light and vital signs were normal. She was known to have asymptomatic thalassaemia minor. A computerised tomography (CT) scan showed a sharp, smooth, linear, foreign body (13 x 2.7 x 2.5 cms) entering the brain from the right temporal bone, antero-superior to the mastoid sinus, crossing obliquely and superiorly to the left side across the right temporal lobe, supra-sellar cistern and basal ganglia to reach the left parietal bone. Blood was noted along the path of the foreign body, mainly in the left basal ganglia and left parietal lobe extending into the lateral and third ventricle with effacement of the left lateral ventricle. Blebs of air were noted intra-ventricularly and intra-cerebrally Figure 1.

Two and a half hours later, a craniotomy was performed. The dura was found to be lacerated. The foreign body was eased out gently (Figure 2). An extradural drain was placed in situ. The intra-operative course was uneventful. Postoperatively, she developed hyperpyrexia, hyperglycaemia, polyuria and severe hypernatraemia. She was managed with antibiotics and careful replacement of fluids guided by monitoring of central venous pressure, serial plasma and urine electrolyte levels and osmolalities. The patient was maintained on controlled hyperventilation to maintain normocapnia and anti-convulsants were used to avoid increases in intra-cranial pressures. Thirty hours later her pupils became fixed and dilated. She became severely hypothermic and hypotensive requiring inotropes. Brain stem function tests on the 3rd day showed brain stem death. Brain perfusion studies 6 days later confirmed brain death. Thereafter, the patient was maintained on minimal supportive measures till her death 15 days later.

Figure 1: CT scan showing the foreign body (13 x 2.7 x 2.5 cm)
entering the right temporal bone and reaching the left parietal bone with blood along its path

This unfortunate incident brings to light some of the serious hazards of fireworks. Fireworks are associated with all forms of dangerous injuries including head injury and burns. 1, 2 Children who are victims are often innocent bystanders (26% of the cases), as in our case.2 Most children affected are in their teens.1 Our case is unusual in the sense that a low-velocity missile caused the injury, causing the same harm as a typical high-velocity missile in the setting of a battlefield, because of the short distance involved. In addition, there was no skull base fracture, which usually occurs in a typical high velocity head injury.3 Fireworks normally do not have pieces of wood in them but some manufacturers spike their products with such objects. The type of foreign body in this case is unusual. Generally, intracranial foreign bodies seen are bullets, pieces of glass, plastic pellets, etc. Our case is unique in the nature and size of the foreign body (Figure 2). The route of entry of the intra-cranial wooden foreign body is commonly through the orbit,4 in this case the entry was through the temporal bone. This route of entry for this type of object has not been described before, as far as we are aware.

The poor prognosis in this case was evident from the beginning. Her admission Glasgow coma scale was 4, even at the smaller hospital that provided the initial care; such an injury is associated with a poor outcome.5 Time of admission to our hospital was more than one hour from the time of injury, though the cranial exploration was performed soon after. The presence of an intra-cranial foreign body per se and its location in the middle cranial fossa is associated with a poor prognosis, compared with foreign bodies in the anterior cranial fossa which are associated with a better prognosis.6 The fact that the object traversed both hemispheres and the associated early post-operative complication of diabetes insipidus put the patient at high risk.6

Diabetes insipidus appeared within a few hours after the surgery. This is a syndrome of inappropriate vasopressin secretion characteristic of severe head injury. Its features include polyuria, hypernatraemia and decreased urine osmolality. It is treated by a combination of vasopressin and appropriate crystalloid administration with close monitoring of plasma and urine osmolalities. We treated our case with the nasal spray form of desmopressin; there are reports in the literature that intravenous vasopressin may be more reliable.7

In conclusion, it is important for the public to be aware of the dangers of fireworks and to use them in a safe, cautious and controlled manner. Early diagnosis, management and transfer to a centre designed for the management of head injuries may improve the prognosis for the type of patient described.

1. Abdulwadud O, Ozanne-Smith. Injuries associated with fireworks in Victoria: an epidemiological overview. J Inj Prev 1998 ; 4:272-5
2. Smith GA, Knapp JF, Barnett TM, Shields BJ. The rockets’ red glare, the bombs bursting in air: firework-related injuries to children. Pediatrics 1996 ; 98:1-9
3. Hadas N, Schiffer J, Rogev M, Shperber YJ. Tangential low-velocity missile wound of the head with acute subdural hematoma: case report. Trauma 1990; 30: 358-9
4. Miller CF, Brodkey JS, Colombi BJ. The danger of intra-cranial wood. Surg Neurol 1977; 7: 95-103
5. Tudor M. Prediction of outcome in patients with missile cranio-cerebral injuries during the Croatian War. Mil Med 1998; 163: 486-9
6. Splavski B, Vrankovic D, Saric G, Saftic R, Maksimovic Z, Bajek G, Ivekovic V. Early surgery and other indicators influencing the outcome of war missile skull base injuries. Surg Neurol 1998; 50:194-9
7. Ralston C, Butt W. Continuous vasopressin replacement in diabetes insipidus. Arch Dis Child 1990; 65: 896-7

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Fireworks injury: temporal bone penetration and a wooden intra-cranial foreign body

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