Diffuse axonal injury grade III

Jenma Rakkini^1*, Subathra Devi. M², Maha Lakshmi³

¹Assistant Nursing Superintendent, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

²Nurse Educator, Kauvery Hospital, Cantonment, Trichy, Tamil Nadu

³Nursing Superintendent, Kauvery hospital, Cantonment, Trichy, Tamil Nadu

*Correspondence

Abstract

Road traffic accidents are a major cause of traumatic brain injury and orthopedic trauma among young adults. This case report describes a 19-year-old male who sustained severe polytrauma following a road traffic accident involving a two-wheeler and a four-wheeler. The patient presented with diffuse axonal injury, multifocal brain contusions, seizures, and an open fracture of the left femur. Initial management included airway stabilization with endotracheal intubation due to low GCS, followed by neurosurgical and orthopedic evaluation. Surgical interventions included wound debridement and external fixation of the left femur. A tracheostomy was later performed for prolonged airway support. This case highlights the importance of early trauma assessment, prompt multidisciplinary management, and critical care support in improving outcomes in patients with severe traumatic brain injury and multiple injuries.

Key words: Road traffic accidents; Tracheostomy; Glasgow Coma Scale (GCS) score

Introduction

Road traffic accidents remain one of the leading causes of morbidity and mortality worldwide, particularly among adolescents and young adults. High-velocity trauma can result in multiple life-threatening injuries, including traumatic brain injury, fractures, and soft tissue damage. Diffuse axonal injury is a severe form of traumatic brain injury caused by rapid acceleration and deceleration forces, often associated with prolonged unconsciousness and poor neurological outcomes. Early stabilization, airway management, neurological monitoring, and timely surgical intervention play a crucial role in patient survival and recovery.

Case Presentation

A 19-year-old male presented with an alleged history of a road traffic accident (RTA) on 04/03/2026 at approximately 10:30 AM. The patient was riding a two-wheeler when he was hit by a four-wheeler, resulting in severe head and left thigh injuries. Following the accident, the patient experienced loss of consciousness and seizures. He was initially treated at an outside hospital, where he was intubated due to a low Glasgow Coma Scale (GCS) score. A CT scan of the brain revealed diffuse axonal injury with multifocal cerebral contusions. In addition, the patient sustained an open fracture of the left femur associated with a severe left thigh injury. On 04/03/2026, he underwent wound debridement of the left thigh along with external fixation of the left femur. Due to prolonged ventilator support and airway management requirements, a tracheostomy was performed on 06/03/2026.

Relevant Clinical Findings

Social History: He does not have any social history of drug addiction.

Allergies: No known medicine or environmental allergies

Past Medical History: No past medical history.

Past Surgical history: No past surgical history

Physical Examinations

BP	110/80 mmHg
PR	128/min
SPO2	100% in mv
Temperature	102◦F
Pupils	R-2mm rtl; L-3mm rtl
GCS	E3 VT M4

Menace reflexes weakly positive

Relevant Investigation

Blood Group and Rh Type - Automated	A Positive	20-03-26 19:36:41
Glucose	103 mg/dL	20-03-26 17:15:01
K +	4.6 mmol/L	20-03-26 17:15:01
02Sat	99.9 %	20-03-26 17:15:01
BE(B)	4.6 mm Hg	20-03-26 17:15:01
pH Blood	7.55 NA	20-03-26 17:15:01
PCO2	31 mm Hg	20-03-26 17:15:01
HCO3(c)	27.1 mmol/L	20-03-26 17:15:01
Chloride Blood	101 mEq/L	20-03-26 17:15:01
Alkaline Phosphatase	195 U/L	20-03-26 19:36:41
Bicarbonate	26 mEq/L	20-03-26 19:36:41
A/G Ratio	0.7.	20-03-26 19:36:41
Indirect Bilirubin	0.7 mg/dL	20-03-26 19:36:41
Sodium	132 mmol/L	20-03-26 19:36:41
AlanineAminotransferase (ALT/SGPT)	36 U/L	20-03-26 19:36:41
Globulin	3.1 g/dl	20-03-26 19:36:41
Direct Bilirubin	0.4 mg/dL	20-03-26 19:36:41
Albumin, Serum	2.1 g/dl	20-03-26 19:36:41
Urea Serum	34 mg/dL	20-03-26 19:36:41
Creatinine	0.6 mg/dL	20-03-26 19:36:41
Chloride	100 mmol/L	20-03-26 19:36:41
Total Protein	5.3 g/dl	20-03-26 19:36:41
Glucose In Glucometer POCT	102 mg/dL	20-03-26 19:36:41
Potassium	4.3 mmol/L	20-03-26 19:36:41
Gamma - Glutamyl Transferase (GGT)	36 U/L	20-03-26 19:36:41
Aspartate Aminotransferase (AST/SGOT)	50 U/L	20-03-26 19:36:41

MRI brain (23.03.2026)

Multifocal resolving hemorrhagic contusions bilateral temporal cortex, right internal capsule, thalamus, midbrain and PONS regions with resolving IVH

Diagnosis

Diffuse axonal injury grade III
Multiple contusions
Septic encephalopathy
Septic Shock

Management

He underwent wound debridement & left femur external fixation for left shaft femur open fracture, Tracheostomy was done on 06.03.2026, patient underwent ORIF & nailing was done on 10.03.2026, after nailing surgical site infection was noted and had persistent fever, blood culture showed klebsiella growth, Urine culture showed candida and repeat urine culture on 18.03.2026 showed pseudomonas growth and came here for further management. The nature of the injury, guarded prognosis, need for ICU care, surgical intervention were explained to patient attenders. He was shifted to IMCU for further management. Orthopedic opinion was sought for? Implant infections, resistance and orders carried out. Plastic surgeon opinion was sought for the same purpose and advised wound debridement. MRI brain done here showed multifocal resolving hemorrhagic contusions bilateral temporal cortex, right internal capsule, thalamus, midbrain and PONS regions with resolving IVH. Repeat cultures were sent. His total counts, procalcitonin and CRP levels were elevated and hence he was treated with antibiotics, anticonvulsant, PPI, analgesics, nebulization and other supportive measures

Out Come

A very guarded prognosis was explained to patient attenders. On 23.03.2026 around 11.55 am the patient went to bradycardia, CPR initiated as per ACLS protocol. Despite resuscitative measures, the patient could not be revived and declared dead on 23.03.2026 around 12.17 PM.

Cause of death

Immediate cause: Cardiac arrest due to sequalae of septic shock

Antecedent cause: Diffuse axonal injury grade III, Multiple contusions

Nursing Management

Maintained airway patency and monitored oxygen saturation.
Provided tracheostomy care and suctioning 2nd hourly.
Monitored neurological status including GCS, pupil reaction, and limb movements in every shift.
Observed for seizures and administered medications as prescribed.
Monitored vital signs regularly and reported any abnormalities.
Administered antibiotics, anticonvulsants, analgesics, and other medications as ordered.
Performed wound care using aseptic technique and monitored for signs of infection.
Repositioned the patient every 2 hours to prevent pressure injuries.
Provided passive range-of-motion exercises to prevent contractures.
Maintained enteral feeding and monitored nutritional status.
Monitored intake and output and maintained fluid balance.
Provided skin care and maintained personal hygiene.
Implemented DVT prevention measures.
Psychological support and regular updates to the patient’s family.
Documented all assessments, interventions, and patient responses accurately.

Discussion

He developed diffuse axonal injury with loss of consciousness and seizures, requiring intubation and ventilator support. The patient underwent wound debridement, external fixation, tracheostomy, and later ORIF with femur nailing. During the hospital stay, he developed surgical site infection, Klebsiella septicemia, and urinary tract infections. Despite intensive medical and nursing care, including antibiotics, ventilator support, neurological monitoring, and supportive management, his condition remained critical. The severe traumatic brain injury and associated complications resulted in poor prognosis.

Conclusion

This case highlights the seriousness of traumatic brain injury following a road traffic accident. Early diagnosis, timely surgical intervention, infection control, and comprehensive critical care are essential for patient management. However, severe brain injury with multiple complications can lead to poor outcomes despite aggressive treatment. Effective multidisciplinary care and continuous nursing monitoring play a vital role in managing such critically ill patients.

Diffuse axonal injury grade III

Diffuse axonal injury grade III

Jenma Rakkini1*, Subathra Devi. M2, Maha Lakshmi3

Nightingale Journals

Jenma Rakkini^1*, Subathra Devi. M², Maha Lakshmi³