wagner6_ch18_case_study_answers.docx

Chapter 18: Traumatic Brain Injury Critical Thinking Checkpoint Case Studies Robert Rose, a 45-year-old taxi cab driver, is brought into the Emergency Department via helicopter following a motor vehicle crash where he was an unrestrained driver. He was ejected from his vehicle after he lost control and hit a large tree. A passing motorist witnessed the crash and called 911. Emergency personnel arrived within 5 minutes. Mr. Rose was found lying on the ground disoriented and combative with a GCS of 14. His medical history is unremarkable. As the EMTs were trying to calm him, he suddenly lost consciousness. His left pupil was 4 mm with sluggish reactivity. His right pupil was 3 mm and briskly reactive. His GCS was now 7. He was intubated and transported to the ED. On arrival to the ED, he suffered a seizure. His pupils were still unequal, with right being 4 mm and left 6 mm and both sluggish to light. His BP was 135/80. He was in sinus rhythm with a HR of 60. His ventilator was delivering his breaths at an assist control mode at a rate of 16 breaths per minute. This activity contains 5 questions. 1. Based on your initial assessment so far, what health problem, if any, do you suspect? Explain why. Answer: Because he was an ejected driver, this increases his risk for TBI. His symptoms are suspicious for epidural hematoma, especially because he was conscious, then became unconscious; however, he may also have other TBIs such as SDH, SAH, DAI; his seizure is likely a result of a head injury; it is troubling that his HR is only 60. It is not known whether he takes medications or has a seizure disorder; he may also have suffered a skull fracture or some other internal injury. 2. What diagnostic test would be indicated for Mr. Rose at this time? Answer: A CT scan is indicated to determine whether he has suffered a TBI or spinal cord injury. It would be very important to immobilize him for transport. 3. What is the significance of his seizure activity? What pharmacological intervention is indicated? Answer: Seizure activity is a complication of TBI that can compromise ICP and CPP, and contribute to secondary brain injury. Intravenous phenytoin or fosphenytoin is likely to be ordered. 4. Why did his pupils become unequal? Answer: The left pupil was larger than the right because of increased pressure on the left oculomotor nerve (cranial nerve III) caused by a space-occupying lesion such as a SDH or SAH. Most likely it was caused by the SDH because after surgical evacuation of that hemorrhage/hematoma, the pupils became equal in size. Sluggishness is also related to increased ICP; alleviation of the pressure caused by the SDH allowed the pupils to respond briskly. 5. What should the nurse monitor frequently? Answer: Vital signs; GCS and neuro assessments; signs of CSF leak, such as rhinorrhea; signs of seizure activity; pain and sedation control. ICP and CPP will also need to be monitored. Hypotension and hypoxia will require immediate intervention to avoid secondary injury.