JAMA Clinical Challenge

Appearance of a Rapidly Expanding Facial Eschar in a Severely Injured Trauma Patient

A, 4 x 4-cm left cheek wound with exposed zygomaticus major muscle. B, Cheek wound after wide local debridement 48 hours after the original procedure. Click on image to view a larger version.

Michael R. Christy, MD
Sachin M. Shridharani, MD
A 21-year-old woman presents to the trauma resuscitation unit via helicopter transport following a motor vehicle crash. She was an unrestrained driver involved in a front-end collision and had a prolonged extrication from the vehicle. At the scene, she was unresponsive and underwent emergency intubation. She sustained multiple severe traumatic injuries including a ruptured spleen requiring abdominal exploration and splenectomy, atlantooccipital dislocation requiring halo placement, bilateral pelvic fractures requiring pelvic binder, and left lower extremity crush injury with multiple open fractures ultimately requiring a left hemipelvectomy. She underwent 38 operative interventions in a 3-week period.

The plastic surgery department is consulted 14 days after the initial crash to evaluate a 4 x 4-cm left cheek wound measuring 2.5 cm deep with exposed zygomaticus major muscle ( Figure 1A). In the ensuing 48 hours, the wound rapidly progresses and develops a necrotic eschar ( Figure 1B).

See the full article for an explanation and discussion.

Author Affiliations: Dr Christy ( mchristy{at}umm.edu ) and Dr Shridharani are affiliated with the The R Adams Cowley Shock Trauma Center and Division of Plastic, Reconstructive and Maxillofacial Surgery, University of Maryland, Baltimore.