Question

Case Study 1: Neurological

Miss Emily Corathers has just celebrated her 21st birthday, for her birthday her parents gave her a new car, it was this car she was driving when she collided with a car at an intersection on her way into town. There was side impact with a large deformity to both cars. There were no fatalities, Emily sustained a full thickness laceration approximately 5cm long on the occipital region of her head, she has scratches to her face and neck and a possible head injury, she has a GCS of 14/15. She is c/o a headache and has vomited once on scene.

Her observations are as follows: • Temperature: 36.2 • Heart rate: 105 bpm • BP: 110/70 • RR: 18 breaths per minute • SpO2: 97% on 6L via a face mask • GCS 14 (E=4, V=4, M=6)

Blood is taken for FBC, EUC, lactate, glucose and blood group and hold. A 12 lead ECG is performed, a 14g IVC inserted into her right cubital fossa. A provisional diagnosis of a Base of skull fracture with extradural haematoma is made. While in the Emergency Department Emily is referred to the neurology team for consultation. It is decided by the neurology team she will need surgical intervention and therefore, need to be transferred to the appropriate tertiary facility. The retrieval team is contacted but it will be a number of hours before they will be there as they are busy at present. Therefore, Emily will remain in the Emergency Department under close observation until the team arrives. 2 hours has past and there is still no sign of the retrieval team, you notice during your next round of observations that Emily is harder to rouse, she now only responding to pain and is speaking using inappropriate words.

Your set of observations reveals: • Temp: 36.2 • HR: 110 (sinus tachycardia) bpm • BP: 110/60 mmHg • RR: 30 • SpO2: 88% on room air • GCS: 11 (E=2, V=3, M=6), pupils unequal L=3, R=4, limb power equal • BGL: 6.2mmol

Questions

1. Identify the elements which signify a deterioration in this patient’s condition. Identify whether these elements of deterioration indicate a rapid response or a clinical review as per the NSW Health, Australia Between the Flags. Justify your decision with the data from the case and relevant support.

2. Using a table construct your communication with the Doctor regarding this patients deterioration employing the ISBAR tool [this section does not need to be referenced].

3. Discuss the pathophysiology of the patients signs of deterioration as they relate to a diagnosis of traumatic brain injury.

Answer 1

1. The elements which significantly deteriorated in this patient is consciousness particularly eye and verbal response and these elements require a rapid response to prevent further deterioration . The Between the Flags (BTF) system is a 'safety net' for patients who are cared for in NSW public hospitals and health care facilities. It is designed to protect these patients from deteriorating unnoticed and to ensure they receive appropriate care if they do. In this case the patient level of consciousness has been deteriorated as she is difficult to arouse , only responding to pain and is speaking inappropriate words .

2. ISBAR tool is a handover communication tool used by the health care staffs to provide or transfer critical health information about patient to other staffs . ISBAR mnemonic full form is identity, situation , background , assessment and request .

Applying ISBAR tool in this situation :-

Identity - includes providing identification of the patient and the reporting staff . In this I will provide a brief introduction about myself and patien

Situation - why are we calling the physician . In this case I will tell him about the deterioration of patients condition

Background - providing the history . In this case the patient had a car accident and she was brought to the hospital . The patient sustained a full thickness laceration approximately 5cm long on the occipital region of her head, she has scratches to her face and neck and a possible head injury, she has a GCS of 14/15. She is c/o a headache and has vomited once on scene. Her vitals were :

Temperature: 36.2 • Heart rate: 105 bpm • BP: 110/70 • RR: 18 breaths per minute • SpO2: 97% on 6L via a face mask.

Assessment - On assessment ,it reveals that her level of consciousness is deteriorating and immediate action has to be taken .

Request - I request you to assess the patient once to avoid further deterioration and emergent steps can be taken .

3. Pathophysiology of traumatic brain injury :-

Brain suffers traumatic injury ,it leads to brain swelling or bleeding causing increased intracranial volume . Rigid cranium allows no room for expansion of contents so, intracranial pressure increases . Pressure on blood vessels within the brain causes slow blood flow to the brain . Cerebral hypoxia and ischemia occurs . ICP continues to raise and blood flow to brain ceases .