CASE STUDY

Case Studies of Pathophysiology

Blood loss has a number of etiologies. It can be lost into body cavities, intravascular or into the external environment. A normal adult human has a blood volume of 5 to 6 liters. The body has mechanisms of regulating blood volume. An increase in volume is termed hypervolemia; the reverse is termed hypovolemia. The 19 year old girl presented in this scenario has lost 1.5 liters due to the laceration inflicted by trauma.

Trauma is a major cause of rupture of body organs and tissues. Due to the laceration caused by a shark bite, damage occurs to the blood vessels. This causes interference in both the arterial and venous circulation. The opening of blood vessels leads to oozing out of blood through them. Mechanisms of the body to prevent blood vessels are initiated, however, the damage is too much for them to contain. The process of hemostasis is not sufficient to prevent the bleeding due to pressure of bleeding and the extent of damage (De Backer, Orbegozo Cortes, Donadello & Vincent, 2014).

The patient has lost a considerable amount of blood that is capable of inducing a hypovolemic shock. It is at this point that the patient is capable of developing unconsciousness or syncope. This is a state that requires intervention. Unlike other types of shock, this is directly involving availability of blood to adequately be used for tissue perfusion. The patient is still conscious and in pain. This is why a Glasgow comma scale review is conducted; she opens eyes to voice and obeys motor commands.

The low volume of blood caused by loss causes an observable decrease in blood pressure beyond normal range; it is 70/45 mmHg. There is an increased effort when breathing showing the struggle to increase PO2 in blood and reduce PCO2 – an effort that strives to increase oxygen concentration in blood and remove acidity. The skin is cool due to insufficient blood from the artery that is warm in nature to regulate body temperature, pale due to anemia (loss of blood) and diaphoretic due to inadequate nutrition by components of blood (Gaieski, Parsons, Hockberger & Finlay, 2016).

The pain is severe that can be ranked 8/10 in the pain facial map. This is evident that the patient is still conscious and part of the skin that contains the pain receptors is affected; perception of pain is relayed to the brain. As explained in the skin, the temperature drop is systemic. The blood as a fluid regulates temperature.

The prime diagnosis of this patient is shock. At a microscopic level, shock is the inability to meet tissue demands of oxygen and nutrients (Zakaria, Althani, El-Gamal, Sartaj, Khan & Singh, 2016). Shock can be hypovolemic, cardiogenic, neurogenic or anaphylactic. This patient has lost blood (1.5 liters) that is able to initiate shock. The patient is still losing blood and it is clear that ignoring her situation can lead to loss of more blood, unconsciousness and eventually death. There are less earnest conditions that this patient present with inasmuch as they can be regarded as emergency states. For instance, the patient is experiencing an 8/10 pain. The pain is solely due to the laceration that is oozing out blood to the external environment. This is why the initial stages of caring for the patient would involve management of pain.

The open part in the laceration has a great predilection to infections due to microbes. Skin, a component of innate immunity has been torn apart or removed. The region is now fully exposed to the highly pathogenic natural environment. To an extent, the patient develops mild immunosuppression. Anemia due to hemorrhage also causes loss of electrolytes and iron (Iron Deficiency Anemia). Anemic patients also present with drowsiness and confusion due to inadequate blood supply to the brain.

The patient is treated in three main ways. First, there is need for the prevention of more bleeding, management of pain and sterilization of wound. After these, better ways of propelling tissue repair can be sought (McConnell & Coopersmith, 2016). The pain level of this condition has been ranked as 8/10. At this point, pain cannot be managed by mild painkillers such as non-steroidal anti-inflammatory drugs (NSAIDS). Such pain can only be handled by opioids such as morphine and morphine like compounds. More bleeding is controlled by covering the laceration with a bandage or clean piece of cloth. Disinfection and sterilization are also essential before placing of the piece of cloth to prevent infections. Secondary to these, the patient should be taken to a surgical ward or relevant health facility to receive blood and get appropriate medical attention. Sweis and Biller (2017) add that during the treatment, it must be ensured that the airway is clear and breathing within normal range. The blood pressure is monitored with desires of elevating it. Treatment continues until normal temperature is achieved and there are no exposures to other infections.

Case Study 2

Different wounds show different effects to the organs they affect. Penetrating wounds are sometimes very severe since they can inflict unbearable trauma to the organs they penetrate through. Penetration to an organ can cause rupture, loss of function, infection and consequent loss of blood. All these can result into death as a terminal complication. Pain inflicted on organs can be sharp or dull (Mira, Gentile, Mathias, Efron, Brakenridge, Mohr & Moldawer, 2017). Sharp pains are associated with sharp objects while dull pains are associated with dull objects.

In this perspective, the patient has been stabbed on the back at the level of T6. This indicates that the stabbing is inflicted in the thoracic region. The thoracic region has a lot of delicate organs including the lung and heart that the person may not survive without. Stabbing the lung will decrease or prevent respiration. Exchange of oxygen and elimination of waste products is crippled or limited. The heart, as the most important body organ, pumps blood from the heart to the lungs for oxygenation and pumps blood to systemic circulation for perfusion of organs (Drosatos, Lymperopoulos, Kennel, Pollak, Schulze & Goldberg, 2015).

The patient has been hurt in some regions of the spinal cord. The spinal cord is a central nervous system that relays impulses from the brain to the organs and from the organs back to the brain. It is a vessel of transfer of impulses within the vertebrae. Motor functions are initiated at the brain and transmitted through the CNS to the organs of motion. The spinal cord that aids this transmission is cut, there is reduced transmission of impulses at certain regions then the patient fails to respond to impulses generated by the brain.

With this patient, there is little pain felt. This can be mistaken and there will be sluggishness in maintaining stability. Patients can feel low grade of pain but there are serious organ effects that are unexplained. For instance, the knife might have reached the heart or lungs. In the heart, very little can be done to correct the situation since the cardiac myocytes are permanent cells and lack a replicative potential (Copstead & Banasik, 2013).

Due to interference of circulation due to damage to heart region, there is predisposition to heart failure. Heart failure is associated with peripheral anoxia. The limbs and extremities cannot receive adequate blood supply to support locomotion and movement. The victim becomes immobile. Blood is unable to properly get into the lower arterial circulation showing possible coarctation or injury to the descending aorta. The knife could have also stabbed the superior aspects or upper region of the spleen. The spleen is also located on the left parts of the abdomen in the left upper quadrant. A stab in the back is more dangerous than one in the front due to nature of the ribs in the posterior sections.

The patient was knocked on the wall and stumped on. This kind of injury can cause fractures and joint dislocations that prevent proper movement. The hip joint, knee joint and ankle joint are all present in the lower limb. Due to the nature of handling, the patient can dislocate any of these joints. Femur and tibia can also experience fracture that requires longer treating. The pain was able to reach only a few pain receptors on the surface of the skin. The fewer receptors in the internal organs that were probably stabbed.

Possible diagnosis in this case is central nervous system and cardiovascular collapse that may be cardiac failure or blood vessel rupture. There is limited perfusion to the extremities associated with the wound inflicted into the thoracic region. The spinal cord may have been injured leading to inability to relay impulses past T6 level that will initiate movement. The sacral plexuses and points where motion exits the spinal cord are not able to function within the expected modality. They cannot move consequently by use of their limbs. The central nervous system relays impulses from the brain to other tissues or vice versa. Its blockade or sectioning will lead to blockade of this impulse.

According to Kimmoun and Levy (2016) treatment in this case is initiated by administration of pain relieving agents such as NSAIDs. The patient’s wound is cleaned and bandaged to prevent both infection and bleeding. The NSAID should be effective and strong enough compared to other drugs in that group to relieve pain caused by stumping and throwing against a wall. The patient is then taken to the neurology department to assess the situation and come up with a satisfactory solution for the case. The treatment should focus on repairing the damaged are and restoring motion if possible. It is ascertained that the airway and breathing are both normal. Temperature elevation desired must be achieved during treatment and exposure to infections at the site handled well.

References

Copstead, L. E., & Banasik, J. L. (2013). Pathophysiology. St. Louis, MO: Elsevier.

De Backer, D., Orbegozo Cortes, D., Donadello, K., & Vincent, J. L. (2014). Pathophysiology of microcirculatory dysfunction and the pathogenesis of septic shock. Virulence, 5(1), 73-79.

Drosatos, K., Lymperopoulos, A., Kennel, P. J., Pollak, N., Schulze, P. C., & Goldberg, I. J. (2015). Pathophysiology of sepsis-related cardiac dysfunction: driven by inflammation, energy mismanagement, or both?. Current heart failure reports, 12(2), 130-140.

Gaieski, D. F., Parsons, P. E., Hockberger, R. S., & Finlay, G. (2016). Evaluation of and initial approach to the adult patient with undifferentiated hypotension and shock. UpToDate, Waltham, MA. Accessed on February 25th.

Kimmoun, A., & Levy, B. (2016). Pathophysiology of shock. Oxford Medicine Online. doi:10.1093/med/9780199600830.003.0149.

McConnell, K. W., & Coopersmith, C. M. (2016). Pathophysiology of septic shock: From bench to bedside. La Presse Médicale, 45(4), e93-e98.

Mira, J. C., Gentile, L. F., Mathias, B. J., Efron, P. A., Brakenridge, S. C., Mohr, A. M., … & Moldawer, L. L. (2017). Sepsis pathophysiology, chronic critical illness, and persistent inflammation-immunosuppression and catabolism syndrome. Critical care medicine, 45(2), 253-262.

Sweis, R., & Biller, J. (2017). Systemic Complications of Spinal Cord Injury. Current neurology and neuroscience reports, 17(2), 8.

Zakaria, E. R., Althani, A., El-Gamal, A. R., Sartaj, F., Khan, M. J., & Singh, R. (2016, March). The Effects of Class IV Hemorrhagic Hypotensive Shock and Its Resuscitation with Fluids and Adjuvant Vasopressors or Cellular Energy Replenishment on the Splanchnic Microcirculation. In Qatar Foundation Annual Research Conference Proceedings (Vol. 2016, No. 1, p. HBPP2329). Qatar: HBKU Press.