Question

Mr. G is a 21-year-old man. He was a pedestrian crossing the street in a marked crosswalk when he was hit by a pickup truck traveling at approximately 40 miles/h (64 km/h). He was ejected onto the side of the road. There is visible external damage to the front passenger panel of the truck. On arrival, emergency medical services personnel determined the patient was awake, not following commands, restless, and agitated. His respiratory rate was 22 breaths/min, and breathing was shallow and unlabored. His oxygen saturation on pulse oximetry (SpO₂) was 92%. There was blood oozing from the right side of his head and obvious deformity to his right leg. He was placed in a hard collar, immobilized, and given oxygen via a 15-L nonrebreather mask. He was immediately transported to the hospital.

Clinical Assessment

Mr. G is admitted to the emergency department. The advanced trauma life support primary survey is completed, and the following assessment findings are identified:

• Airway: Moaning incomprehensibly

• Breathing: 24 breaths/min, shallow; obvious right-sided deformity (flail chest)

• Circulation: Pale, cool; palpable carotid and femoral pulses

• Disability: Glasgow Coma Scale score 13 (motor, 5; verbal, 3; eyes, 4); moving all four limbs but not to command

• Exposure: Right scalp laceration; several abrasions; lacerations over face, back, and legs

Diagnostic Procedures

Admission x-ray shows fractured right femur. Computed tomography (CT) scan shows a small subdural hematoma and liver laceration.

Medical Diagnosis

Mr. G is diagnosed with subdural hematoma (secondary to trauma), flail chest, fractured ribs, fractured right femur, and liver laceration.

Admission to Critical Care Unit

On admission to the adult critical care unit after the CT scan, reassessment of the patient is done with the following assessment findings: Heart rate, 142 beats/min (sinus tachycardia); respiratory rate, 30 breaths/min, short, shallow, and labored; blood pressure, 85/46 mm Hg; SpO ₂, 86%; temperature, 96.3°F (35.7°C); Glasgow Coma Scale score 7. The patient is difficult to arouse.

Questions

1. What are your immediate priorities for this patient?

2. What care do you anticipate Mr. G will require in the next hour? What care will he require in the next 4 hours?

3. Do you anticipate that Mr. G will require surgery? Explain your rationale.

4. What problems might you anticipate Mr. G may experience as a result of his injuries?

5. What interventions must be initiated to prevent and manage any possible problems?

6. What type of questions might you anticipate the family will ask you? How will you respond?

7. What possible learning needs would you anticipate for this patient?

Answer 1

ANSWERS :

1. Immediate priorities to the patient includes :

* Shift patient to critical care unit

* Administer oxygen therapy to patient

* Continuous monitoring of vital signs

* Controlling of bleeding caused by subdural hematoma, rib fractures by administering anti coagulants

* Check for conscious level of patient using glasgow coma scale

* Plan for surgery if bleeding is not controlled and patient is developing worse symptoms

2. Mr. G requires the following care within the next hour :

* Controlling of bleeding

* Maintaining of normal blood pressure to avoid heart failure or cardiac arrest

* Monitoring of vitals

* Assess for the depth of injury, level of fractured areas and need for surgery

* Administer oxygen therapy using oxygen masks or catheters to avoid patient going to a state of cyanosis

* Check for conscious level of patient, because it is important to make the patient in awaken state

- Mr. G requires the following care in the next four hours :

* Even though all the measures which has discussed above if the patient condition is not coming to normal plan for surgery to prevent further complications

* Plan for surgery to remove blood clots in the brain as patient develops seizures and go to coma state if not removed at a correct time

* Surgery to be planned for rib fractures as they cause for lung collapse or heart friction leading to cardiac arrest

* After administering of medications check for conscious level again to identify whether he is responding to the commands or he is in coma state.

3. As the patient medical diagnosis includes subdural hematoma, flial chest, fractured ribs and femur, so it is important to go for surgery.

- Rib fractures cause friction of lungs and can cause collapse of lungs and heart which leads to death of the patient

- Removal of the blood clot in the brain to prevent trauma and impaired functioning of brain

- Prior importance to be given for blood clots in brain, repair of rib fractures, as the blood clot is not removed on time it leads to coma state of patient.