CASE PRESENTATION (CASE # 3)

Manny is a 32-year-old man who fell from a 2storey building and hits his head on a large rock. He experienced momentary loss of consciousness and when the paramedics got to him, he was already awake. The paramedics had applied a cervical collar on him.

1. Why was a cervical collar placed on Manny?

The paramedics or pre-hospital care providers assume that by applying a collar to the patient, the patient is safe from any further injury to their whole spinal cord. Cervical collars restrict the movement of a patient's neck after an injury, bone fracture or surgery. Emergency personnel often use cervical collars when transporting a patient from the scene of an accident to a hospital.

The main purposes of cervical collars:

Temporary support to the head of a sitting or standing patient until the patient can be placed in a supine position. To free the hand of Officers while the patient is being moved & splinted to a Full spine board. To reduce compression of the cervical spine caused by the head. Minimizing axial loading / unloading of the spine that takes place in an ambulance during transport (i.e. acceleration / deceleration). To highlight to other Health Care Providers that the patient is a potential or actual cervical spine injury victim.

Neuro exam reveals GCS 12, full sensation Complaining of headache and becoming increasingly lethargic

2. While you are finishing your assessment on Manny, he starts talking incoherently and drifts off to sleep, what is your next action?
Depending on the score, head injuries are classed as:
Minor: a score of 13 or more Moderate: a score of 9-12 (GCS: 12) Severe: a score of 8 or less

If your GCS score is 14 or less, your condition will need to be treated in hospital.

Symptoms of a moderate to severe head injury:

Unconsciousness, either very briefly (concussion) or for a longer period of time Lethargy, difficulty staying awake or still being sleepy several hours after the injury Speaking incoherently or difficulty speaking, such as slurred speech Headache or a lasting headache since the injury

Next actions will be:

Checking if the airway is clear Checking if the client is breathing, and starting cardio-pulmonary resuscitation (CPR or mouth-tomouth) if not Checking vital signs: BP, PR, RR, Temperature Stabilizing neck and spine, for example ensuring proper application of cervical collar Assess for any signs of bleeding

Next actions will be: (Contd)

Reassessing GCS If possible, check the level of oxygen in blood through pulse oximetry Assessing reaction of clients pupils to light Splinting any other fractured or broken bones (strapping them into the correct position) Providing pain relief if the client is complaining from pain

Unresponsive to verbal stimuli Responds only to painful stimuli Pupils unequal and non-reactive to light

3. What is Mannys GCS at this time? What does this mean and what will you do next?
E: pupils are not equal and non-reactive to light = 1 M: responds only to stimuli = 5 V: unresponsive to verbal stimuli = 1 GCS: 7

Next Actions?

 Brain injury is classified as: Severe, with GCS 8 COMA Moderate, GCS 912 SUFFERS SEVERE HEAD INJURY Minor, GCS 13. CONSCIOUS, COHERENT Doctor ordered Mannitol 500 ml / IV

4. What is Mannitol and why is it being given to Manny?

Mannitol, a 6-carbon sugar, is widely used in head injury management. It is an osmotic diuretic and can have significant beneficial effects on ICP, cerebral blood flow and brain metabolism. Mannitol has two main mechanisms of action. Immediately after bolus administration it expands circulating volume, decreases blood viscosity and therefore increases cerebral blood flow and cerebral oxygen delivery.

 Its osmotic properties take effect in 15-30 minutes when it sets up an osmotic gradient and draws water out of neurons. However after prolonged administration (continuous infusion) mannitol molecules move across into the cerebral interstitial space and may exacerbate cerebral edema and raise ICP.

 Mannitol is therefore best used by bolus administration where an acute reduction in ICP is necessary. For example the patient with signs of impending herniation (unilateral dilated pupil / extensor posturing) or with an expanding mass lesion may benefit from mannitol to acutely reduce ICP during the time necessary for CT scanning and/or operation. Mannitol is wholly excreted in the urine and causes a rise in serum urine and osmolality. Patients with poor renal perfusion (shock), sepsis, receiving nephrotoxic drugs or with a serum osmolality over 320mOsm are at risk of acute tubular necrosis. Hypolaemia should be avoided with the infusion of isotonic fluids as necessary.

CT scan reveals large epidural hematoma on the Right Hemisphere Transported to OR right away for evacuation of hematoma On the way to OR, doctor instructed the nurse to hyperventilate the patient to blow off more CO2

5. Why is this being done to Manny? Give the rationale for this action.
Hyperventilation itself reduces the carbon dioxide concentration of the blood to below its normal level, raising the blood's pH value, initiating constriction of the blood vessels, which supply the brain, and preventing the transport of certain electrolytes necessary for the function of the nervous system. During these situations, you are breathing out more than you are breathing in, which means you are blowing off a lot of CO2 (carbon dioxide).

 As with other types of intracranial hematomas, the blood may be removed surgically to remove the mass and reduce the pressure it puts on the brain. The hematoma is evacuated through a burr hole or craniotomy.

6. What would be your priority nursing interventions to prevent increased ICP after surgery?

Monitor patients vital signs and neurologic status. Check him every 15 minutes for the first 4 hours, then once every 30-60 minutes for the next 24 to 48 hours. To help prevent increased ICP and protect his airway if his LOC is decreased, position the patient on his side. Elevate his head 15-30 degrees to increase venous return and help him breathe more easily. With another nurses help, turn him carefully every 2 hours

 Observe the patient closely for signs of increased ICP. Immediately notify the physician if you observe worsening of mental status, pupillary changes or focal signs such as increasing weakness in an extremity Encourage deep breathing and coughing, but warn him not to do this strenuously. Suction gently as ordered.

 Administer fluid as prescribed to maintain normal fluid balance. Monitor and record I and O, check urine specific gravity every 2 hours , and weigh the patient as ordered. Check serum electrolyte levels every 24 hours, and watch the patient for signs of imbalance. Low potassium levels may cause confusion and stupor; reduced sodium and chloride levels may produce weakness, lethargy, and even coma. Because fluid and electrolyte imbalance can precipitate seizures, report any of these signs immediately.

 Provide wound care. Make sure the dressing stays dry. Notify the physician of excessive bloody drainage, possibly indicating cerebral hemorrhage, or of a clear or yellow discharge, which may indicate a CSF leak. Also monitor for signs of wound infection, such as fever and purulent discharge. Provide supportive care. Ensure a quiet, calm environment to minimize anxiety and agitation and help lower ICP. Administer anticonvulsants as ordered and maintain seizure precautions. Provide other ordered medications, such as steroids to prevent or reduce cerebral edema, stool softeners to prevent increased ICP from straining during defecation and analgesics to relieve pain.