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 (
See the full
an explanation and discussion.
Author Affiliations: Dr Christy (
) 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,