Question

Case 6

Ross Adams is a 17 year old football player in high school. While walking to the sideline, Ross took off his helmet and appeared confused. Falling to his knees, he began to vomit. He complained of severe head pain, nausea, and vertigo. His coach called 911.

When the EMTs arrived, he was alert and oriented. The EMTs asked whether he had fallen or been hit on the head, and he reported that he was hit a couple times over the last couple days, but not in the last few minutes. His skin was pale, cool, and moist. His pulse was 54, regular, and strong. His respiration was 16, abnormal rhythm, shallow, and labored. His blood pressure was 157/102 mmHg. His right pupil was 5mm and nonreactive to light, and his left pupil was 3mm and minimally reactive. Recognizing the signs of increased intracranial pressure, the EMTs immediately transported him to the nearest emergency department.

Upon arrival at the emergency department, he vomited again. His blood pressure was 200/100 mmHg and his pulse was 48. His reflexes were intact. A nurse administered mannitol 1g/kg rapidly by intravenous push.

A CT image of the brain revealed an acute 1.3 cm subdural hematoma in the left hemisphere. At this point, Ross became unresponsive. He was taken to the operating room for an emergent craniectomy and decompression.

Questions:

22.Which of the signs and symptoms indicated that Ross had increased intracranial pressure? For each, why?

23.Why did Ross’s blood pressure continue to rise?

24.Why was mannitol administered? What does it accomplish and how does it work?

25.How does a subdural hematoma compare with an epidural hematoma, a subarachnoid hemorrhage, or intracerebral hemorrhage in terms of cause and manifestation?

Case 1

Cindy Brown is a 80 year old widow who was brought into the emergency room one evening by her brother. Early in the day, Mrs. Brown had seen bright red blood in her stool. She continued with her daily activities: she cleaned her house in the morning, had lunch with her daughter, and volunteered at the local library. However, the bleeding continued all day, and she started feeling light-headed. By dinnertime she decided to ask her brother for help. Mrs. Brown does not smoke or drink alcoholic beverages. She takes aspirin, as needed, for arthritis.

In the emergency room, Mrs. Brown is confused and anxious. Her skin is pale, cool, and moist. Her pulse is 116, regular, and weak. Her respirations are 22, regular, normal volume, and unlabored. Her blood pressure is 90/60 supine. The nurse takes a standing blood pressure as well, and it is 75/45. Her hematocrit is 29%.

A colonoscopy shows that the bleeding came from a herniation in the colonic wall. Mrs. Brown’s physician orders a normal saline infusion, which the nurse starts, and a blood sample to be drawn to be typed to prepare for a blood transfusion. Mrs. Brown receives two units of whole blood, and is admitted for observation. She is instructed not to take aspirin.

Questions:

1. Describe the body’s sequence of events that led to Mrs. Brown becoming light-headed and needing to seek help.

2. Discuss the physiological reason for each of the signs that you assessed (skin, pulse, respiration, blood pressure, hematocrit).

3. Discuss the rationale behind each of the treatments provided (normal saline, blood transfusion, no aspirin).

4. Had her blood loss been more severe, Mrs. Brown might have received a low dose of dopamine. Why is low-dose dopamine helpful in the treatment of hypovolemic shock?

Answer 1

Case6

22, Signs and symptoms of increased intracranial pressure in this case include :

Vomiting

Hypertension

Pupil nonreactive to light

Shallow and irregular breathing

23, Once the Intracranial pressure approaches the level of the mean systemic pressure, cerebral perfusion falls. The body's response to a fall in cerebral perfusion fall is to raise systemic blood pressure and dilate cerebral blood vessels. So it will enhances the blood circulation to brain

24, Mannitol is an osmotic diuretic, which reduces the water content and reduce the intacranial pressure. Mannitol decreases blood viscosity and intracranial pressure decrease. Mannitol also reduces ICP by reducing cerebral parenchymal cell water.

25, Epidural bleeding occurs between the skull and dura matter, whereas subdural bleeding occurs between the dura and arachnoid.

Subdural hematoma characterized by seizure, vomiting, lethargy, loss of conciousness etc.

Epidural hematoma characterized by initial loss of conciousness, nausea, vomiting etc.

Subarachinoid hematoma characterized by abstract onset of headache, meningeal irritation, neck stiffness etc.

Intra cerebral hematoma characterized by nectual rigidity, seizure, loss of conciousness etc.

Case1

1,Loss of blood from body lead to decreased circulatory blood in body. This also lead lack of blood in brain to function and dizziness occur. So the person need assitance.

2, Skin become pale due to the loss of blood and decreased circulatory blood. Pulse rate is rapid and weak. Tachycardia occur because of the heart try to pump more blood when the circulatory blood volume decreases this is why heart beat faster but due to lack of blood the pulse should be weak. Blood pressure is low because of the vasodilation is occur in response to body's response to decreased circulatory blood volume. Respiration may be shallow or rapid. Because the body need oxygen while hypovolemia blood cannot transport enough amount of oxygen to cells it will increase the respiration

3, Normal saline is administered to prevent dehydration. It is a hydration treatment. Blood transfusion is done to maintain the normal circulatory blood volume. Aspirin should be avoided because aspirin induce bleeding.

Dopamine increases the cardiac output, so it will help in the treatment of hypovolemic shock. Dopamine help the heart to pump more amout of blood.