Question

Read the following case:

On the morning of January 11, 1983, twenty-five-year old Nancy Cruzan lost control of her car as she traveled down an icy deserted county road in Missouri. The car overturned, and she was discovered, lying face down in a ditch, without detectable respiratory or cardiac function. Emergency medical technicians were able to restore her breathing and heartbeat, and she was transported to a hospital in an unconscious state. A neurosurgeon there diagnosed her as having sustained probable brain damage, compounded by significant oxygen deprivation. The estimated length of the period without oxygen was twelve to fourteen minutes. (Permanent brain damage generally results after six minutes without oxygen.)

Cruzan remained in a coma for approximately three weeks, and then progressed to an unconscious state in which she was able to orally ingest some nutrition. In order to ease feeding and further her recovery, surgeons implanted a feeding and hydration tube with the consent of her then husband. In October 1983, she was admitted to a state hospital. Subsequent rehabilitative efforts proved unsuccessful. It became apparent that she had virtually no chance of regaining her mental faculties, and that Cruzan was in a persistent vegetative state (PVS).

Answer the following question:

1.     Should the emergency medical responders provide treatment and why? Provide a reasoned opinion and define terms (50% or 25/25)

2.     Should the physician continue treatment and why? Provide a reasoned opinion and define terms (50% or 25/25)

Answer 1

Q)1) Should the Emergency medicine responders provide treatment and why?

In road traffic accidents , falls, sports injuries and acts of violence result in injuries to brain like Concussion, Contusion and Hemarrohage ( Subdural, epidural. As a Emergency medicine responder he has to stabilise the ABC    ( airway, Breathing and circulation ), the people what they have done in the given case they stabilise breathing and Heart rate.

Why means: Coma is deep state of unconsciousness , may occur not only RTA's also from drugs,toxins and certain diseases of liver , kidney etc.

- the outcome of coma depends on cause, severity and site neurological damage

- individuals who recover from coma may be left behind with significant physical, intellectual and psychological disabilities that require special and long term attention,

- recovery usually occurs gradually, while many individuals recover full awareness, some never progress beyond very basic responses that case like Persistent Vegitative State.

- Oxygen deprivation causes the cardiac arrest ,a sudden cutoff blood flow and oxygen to the brain known as hypoxia or anoxia and person may suffer from coma if she survives this attack.

- A stoppage of oxygen to the brain for

more than 4 minutes can cause irreversible brain damage, similar brain hypoxia occurs in Drowning, Choking or Strangulation.

Q)2) Should the physician continue treatment and why?

Basic approach to the management of the victims of Traumatic Brain Injury

1) to prevent secondary and delayed insults after the initial neurological damage,

2) an improved outcome is attributed to the adaption of evidence based clinical practice guidelines,

3) common causes to remember:

- Hypotension,

- Hypoxia,

- increased ICP,

- seizure,

- Electrolyte abnormalities,

- cerebral vasospasm,

- Coagulopathy and DIC,

- systemic or central nervous system infections,

- Dural Sinus Thrombosis,

- carotid or vertebral artery dissection,

- Deep vein thrombosis.
  
   To prevent or manage the above conditions, physician must be continue his efforts to save the life.

Summary of the topic : the emergency medicine responders has to stabilise the ABC of resusitation, intubate any patient with concern for airway or breathing, hypoxemia or hypercarbia and transfuse patient with significant blood loss, Seizure control by administration of anti epileptic drugs, Cervical spine stability use spine board and cervical collar until stability assessed.

   The physician has to continue his treatment following recommendations for management of the head injured patient. Avoid systolic blood pressure <90mmhg, maintain spo2 > 90%, hyperventilation to a PaCo2<25mm hg is not recommended, ICP monitoring, Maintain cerebral perfusion pressure between 50 and 70 mmhg, anti epileptic drugs should be administered prophylactically for the first 7 days and discontinued in pts without evidence of seizures.