Question

Billy is a 15 y/o with his new drivers permit out driving with mom. She screams stop, but he runs through the red light and is T-boned by a large truck. There is significant intrusion into the driver’s side of the car. Extrication of Billy took 45 minutes.

Upon arrival to the ER Billy is lethargic, opens his eyes briefly to voice and is able to follow simple commands with much prompting. When asked how he’s doing he occasionally mumbles “ouch”. He is cyanotic on 100% NRB mask. He is tachypneic and the left side of his chest wall demonstrates paradoxical movement with an obvious flail segment. Upon auscultation breath sounds are absent on the left side and diminished on the right. He has significant ecchymosis on the right chest area.

VS are: B/P 70/38, P 136, RR 36, T 95.2 and O2 Sat is 79%.

1. (5 points) What is Billy’s Glasgow Coma Score?

Eye___ Verbal____ Motor____ Total____   

What is you main priority for this patient?

Why?

What orders do you anticipate?

CXR reveals multiple anterior and posterior rib fx on the right and left sides of the chest. There are noted pulmonary contusions and a pneumothorax on the left. Billy is becoming progressively more confused and lethargic.

2. (1 point) What do you think is happening with this patient?

Lab work is as follows:

WBC   14,600             4.8-10.8 K/u    

Hgb    16.7                 14.0-18.0 g/

Hct      46.2                 42.0-52.0 %

Plts      466,000           164,000-446,000

Na      139                  135-145

K         3.8                   3.6-5.5

Cl        104                  96-112

Cr        1.3                   0.5-1.4

BUN   24                   8-22

Glu      167                  70-110

PT       14.4                 11.0-14.0

PTT    19.6                 23.5-33.5

INR     1.14                 0.86-1.14

3. (4 points) Interpret these lab findings and any concerns you might have regarding the labs.

Upon arrival to the ICU, your assessment reveals a very hard to arouse individual, vented on an AC of 12, FIO2 100%, PEEP +5, PERRL, You can’t get Billy to follow commands.

4. (2 points) What might be happening? What would you do?

Four hours into your shift and caring for Billy he is posturing to deep pain. His pupils are unequal.

4. (1 point) What are your nursing priorities?

An ICP bolt is inserted with opening pressures of 35.

5. (3 points) What is the normal ICP?

What is the normal Cerebral Perfusion Pressure?                  

What might be the anticipated treatment?

Throughout the next 24 hours Billy’s course is extremely unstable. He blows his left pupil during rounds the next morning.

6. (2 points) What might be happening?                           What orders would you anticipate?

On day 2 & 3 things continue to deteriorate. ICPs range from 28-58 with peaks in the 80’s during care.

        7. (1 point) What drug options may be considered for someone like this?

On day 10 (6 days into drug therapy initiated in question 7) you note that the ICP maintaining between 4-10. His pupils are still dilated and no response to light. Vital Signs are stable and he has been successfully weaned to an FIO2 of 35%.

8. (2 points) What are the next steps for this patient?     How long might it be before you see any significant changes?

On day 14 you see fluttering of the eyelids and spontaneous movement in the patient’s right arm.

On day 16 Billy follows simple commands with the right hand.

On day 21 Billy is successfully weaned from the vent and placed on a T-piece. He vigorously follows commands with the right arm and leg. PERRL. He is tracking well.

Day 22 the ETT is pulled and Billy attempts to make sounds.

Day 24 he is transferred to the step-down unit.

9. (2 points) What type of head injury might he have suffered? What care issues might we have forgotten for this patient?

10. (2 points) Discuss any technological and ethical concerns you might have for this patient.

Answer 1

1. Glasgow coma score. Eye opening- 3 opens eyes briefly to voice verbal - 2 mumbles 'ouch' motor- 6 simple commands

Total- 11

Fluid resuscitation and oxygen inhalation is the priority for this patient because patient is facing hypotension which might be due to blood loss if not treated patient will go into hypovolemic shock. Due to chest trauma patient is not able to take in the oxygen hence going into hypocrisy which requires immediate action.

2. Due to flail chest trauma. Patient is compromised with tissue prefusion as evidenced by hypotension and hypocrisy which is the reason for deterioration of billy's condition.

3. The investigation reports shows elevated total counts due to haem concentration. Due to hypotension the blood circulation to kidney has reduced which has impaired renal function hence the creatinine levels are on the border level. This also indicate the increase in blood urea nitrogen level. And due to dehydration even the blood glucose level is on the higher side.

4.due to low prefusion to all the organs in the body. Patient can develop a multiple organ dysfunction. The patient is on ventilator support and can require cardiopulmonary resuscitation anytime. Frequently assessment of the patient is very important with monitoring of vital signs every now and then is required.

4.1 the priority at that point of time is to access the respiratory and neurological status of the patient. Increased icp indicates hypercapnia that is increase in carbon dioxide levels which has increased the intracranial pressure. It requires hyperventilation on oxygen via ventilator. And inform the ICU doctor about the increased icp.

5. Intracranial pressure is the pressure inside th skull spine and cerebrum. The normal ICP is 5- 15 me of HG. Anticipated treatment strategy is to hyperventilate the patient and administer if mannitol is prescribed by the doctor with hypertonia solutions.

6. Due to increased intracranial pressure their is a lot of pressure on the brain cells and spine which can damage the brain tissue permanently and there are chances of brain herniation.

7. IV mannitol and hypertonic solutions

8. Increased icp had caused papillary edema and dilatation.

And the delay in progress may be due to temporary brain damage.

9. A traumatic head injury with a cerebral edema or a haemorrhage. The care issue forgotten may be neurological assessment.. And neglected neurological assessment as we were more concentrated about the chest trauma.

10. Families of brain injured patients should be compassionately counselled that, despite provocative and highly publicized case report, there technologies while promising are currently investigations and have not been sufficiently validated. Functional neuroimaging technology also impact on ethical issues of treatment, rehabilitation and production.