Complex or critically unwell patient with trauma
12Nursing: Trauma Care
COMPLEX OR CRITICALLY UNWELL PATIENT WITH TRAUMA
Cliffie arrives at the Emergency Department (ED). He presents a valid trauma case after falling off a cliff approximately a day before arriving at the ED. The physical examination of the patient following his arrival at the ED reveals evidence of a stabbing at the abdomen before falling off the cliff yesterday. The approximate height of the cliff was 6 to 7 metres. The patient provides unclear statements about the incidences that occurred prior to the stabbing and eventual throwing off the cliff. The patient is also unwilling to provide an account of the events that transpired before the incident. The patient only remembers the fall and a brief loss of consciousness (LOC) after which he woke up to find himself lying on a rock. Cliffie was not able to trace the way back home during night, it was not until morning that the patient was able to trace his way back home. However, the patient reported having experienced walking difficulties emanating from the pain in the left foot. Cliffie also tolerates a diet as well as vomits. The patient admits that a sharp object of an approximate length of 15cm was used to stab him on the fateful day. The emergency department professionals identified four major possible implications of the patient’s case before resorting to conducting both a CT head scan and a CT abdo pelvis scan. The implications include a possible wrist fracture, leg fracture, facial fracture and an abdominal stab wound.
Emergency Management of the Patient
The CT Head Report
Upon arriving at the hospital, Cliffie underwent a CT head scan. The report targeted to determine whether or not the patient had suffered head injury. In conducting the scan, Jarrett obtained helical non-contrast head images with the use of multiplanar reconstructions as was the standard procedure in the department. The findings of the scan revealed a subarachnoid haemorrhage in the anterior fall interparenchymal extension into the middle of the left frontal lobe. The scan revealed a rim of vasogenic oedema that surrounded the interparenchymal haemorrhage. The scan also focused on contusion by focussing on the hyperdensity of the left precentral gyrus’s superior portion. Scans conducted on other parts of the cranium did not reveal acute blood accumulation.Moreover, the head scan also revealed a preserved grey-white matter differentiation. Both the cisterns and ventricles were patent. The scan did not reveal a case of midline shift. The outlining of the CFS spaces of the posterior cerebellum, brainstem and cranial fossa was also normal. The scan did not identify herniation of the cerebellar tonsillar.
The scan also revealed an undisplaced fracture on the bone windows. The position of the fracture was the left basi-occiput that has a lateral extension into the left occipital condyle. The scan also revealed an extension of the fracture line to the left jugular foramen. However, an examination of the jugular foramen contours did not reveal any disruptions. The outlining of the calvarium and the facial bone was also normal. The orbits were also intact and symmetrical. The mastoid air cells and paranasal sinuses were also clear. An examination of the bilateral temporomandibular joints revealed that they were intact. In essence, the major finding of the CT head scan was the existence of acute subdural haemorrhage in the anterior falx located in the middle of the left frontal lobe having the intraparenchymal extension. The superior left frontal lobe also revealed gyral contusion as evidenced by the bruise that resulted in the rupturing of the blood capillaries (Alvis-Miranda et al. 2013). The other significant revelation was the presence of an acute undisplaced fracture of the left basi-occiput that extends laterally into the left jugular foramen and the left occipital condyle. The left jugular foramina did not reveal any cortical irregularity.
The CT Abdo Pelvis Scan
An in-depth analysis of Cliffie’s case necessitated a further assessment for intercranial injury. The assessment entailed the use of multiplanar reconstructed post-IV-contrast images of the pelvis and abdomen. There scan revealed several findings. From the findings, it was evident that there was no solid or hollow viscus injury. The scan did not reveal aortic dissection or rupture. The abdomen/pelvis did not reveal any free fluid or air. A scan on the liver revealed multiple cystic lesions. Segment 7/8 of the liver revealed the largest cystic structure that measured 5mm and 17HU. The appearance of the kidneys, adrenal glands, pancreas, spleen, and gallbladder was also unremarkable as portrayed by the scan. The configuration and calibration of the small and large bowel loops was also normal. The L2 vertebral body superior endplate revealed a fracture that had a step deformity. The deformity was on Se 6, Im 34. The scan also revealed a possible fracture of the L1 superior endplate located on Se 6, Im 34.
A scan on the anterior abdominal wall’s midline skin revealed a break at the kidney level on Se 2, Im 33. The scan also revealed a hyperdense streak that extended inferiorly to the umbilical’s level that is superficial to the linea Alba on Se 2, Im 37. The results are in accordance with knife laceration disregarding the presentation of intra-abdominal extension. The abdomen does not reveal any associated gas locules. From the results of the scan, there are three major findings. The existence of cystic lesions in the liver suffices to be one of the findings. However, the presentation of lesions necessitates further examination with the help of an ultrasound. The second finding is the existence of a fracture on the superior endplate of the L2 vertebral body. The fracture revealed a step deformity on Se 6, Im 34. The other important finding of the scan on the abdomen is the probable existence of a fracture on the L1 superior endplate located on Se 6, Im 34.
Improvements in the Management of Head Injury
The fact that the patient had evidence of a possible facial fracture implied the necessity of minimising secondary brain injury. The minimisation of secondary brain injury has turned out to be a crucial and imperative intervention for trauma patients that present head injury. Maintaining cerebral oxygenation and perfusion suffices to be the two main reasons that warrant reducing secondary brain injury. It is evident that approximately 65% of trauma patients that present to hospitals with head injury succumb to the injuries as a result of secondary brain injury. Secondary brain injury emanates from hypotension or hypoxia. Even though Cliffie had presented to the hospital the following day after falling and suffering injuries on the head and abdomen, it was still necessary for the emergency team to abide by the ABC’s of dealing with a trauma patient. These include airway, breathing and circulation (Mock et al. 2004).
It is imperative for the trauma team to recognise the significance of the ABC’s of trauma care in all trauma patients that present with head injuries to the ED. The other significant necessity for minimising secondary brain injury in patients that present head injury is to offset the likelihood of raising intracranial pressure (ICP). Avoiding over-hydration suffices to be the main avenue of reaching the goal. The nursing intervention is appropriate particularly for patients such as Cliffie that are haemodynamically stable. The fact that Cliffie spent the night in the bush after suffering the stab on the abdomen and bleeding increases the likelihood of the patient to present hypovolemia. Hypovolemia is the condition where the patient presents low blood volume in the body (Koyfman & Trevor 2014). As a result, there is a decreased volume of blood that circulates in the patient’s body. For such patients, the use of appropriate hydration is necessary as a measure of preventing hypotension in all hospital settings.
In essence, it was necessary for the ED to monitor the intracranial pressure for appropriate indications keeping in mind that the patient had undergone a CT scan of the head to determine any possible head injuries. In the event that Cliffie presented raised ICP, the recommended intervention measures include sedation, paralysis, osmotic dieresis, drainage of the cerebrospinal fluid and hyperventilation. However, it is evident that Cliffie’s case did not require such interventions unless of the patient revealed signs of raised ICP. In the event that Cliffie presented the symptoms of adverse ICP, the use of the above measures would be necessary in the presence of a neurosurgeon (Koyfman & Trevor 2014). In the event that there are limited facilities to transfer Cliffie to a tertiary care facility having a neurosurgeon, the trauma team can still implement the measures provided that there is a general surgeon that has experience in neurosurgical expertise. Approximately 10-20% of comatose patients present intracranial mass lesions with pressure. Improving patient outcome depends on the timely decompression of the lesions. The existence of computerised tomography (CT) in the facility facilitates the treatment of lesions.
There are a number of reasons that impede emergency facilities from availing CT equipment to scan patients that present a high likelihood of intracranial mass lesions. Frequent breakdowns of the equipment, high costs of using the equipment and the included mandatory fees are some of the reasons that deter emergency facilities from using the equipment on patients (Koyfman & Trevor 2014). However, the complete treatment of the patient necessitated a CT scan to determine the presence of intracranial mass lesions. It is evident that Cliffie fell under the Glasgow coma scale of less than 8. However, the mere fact that Cliffie presented a head injury was sufficient to warrant a CT scan of the head to reveal intracranial mass lesions. The other possible area of improvement in the trauma care process was the reduction of the waiting time prior to conducting the CT head scan. Since Cliffie had spent the night in the bush without any medical intervention, the CT scan of the head should have been performed with immediate urgency in a period that does not exceed 2 hours following the patient’s presentation at the ED.
The findings of the CT head scan revealed acute subdural hematoma (SDH). This entails a rapid collection of clotting blood that is external to the brain and under dura’s inner layer (Koyfman & Trevor 2014). The rapid collection of clotting blood is also external to the arachnoid membrane. The failure of the trauma team to treat the condition will transform its state from acute to chronic or sub-acute. It is evident that Cliffie’s state will transform into sub-acute or chronic in the event that there is no treatment of the acute condition approximately 3-7 days and 2-3 weeks respectively following the occurrence of the incident. Following the diagnosis of SDH in Clifie, the availability of a neurosurgeon is imperative. However, a general surgeon with substantial experience in neurosurgical operations can also deal with the condition. Considering Cliffies performance on the Glasgow coma scale, an endotracheal intubation is necessary. The intubation is a guarantee of the protection of the airway during the entire process.
Obtaining the CT head scan was a proper move by the trauma team that handled Cliffie. The appropriateness of the scan was the fact that the patient had suffered a head injury and had experienced a clear LOC; the two requirements for a CT head scan. Cliffie also exhibited focal neurological signs as well as disorientation thereby escalating the need for a CT head scan. The next intervention measures include the reduction of ICP and the optimisation of venous flow. In order to implement the measures, the trauma team should raise Cliffie’s head by 30o while the patient is lying on the bed. It is also necessary to maintain the head and the neck in a midline position to ascertain venous outflow optimisation. Cliffie should also undergo hyperventilation to attain the required carbon IV oxide pressure (pCO2). Attaining a pressure of 30mm Hg is effective towards the short-term reduction of ICP. The trauma team should ensure that they do not reduce pCO2 to a level that is lower than 25mm Hg. Decreasing ICP necessitates the use of 0.25 g/kg of intravenous mannitol (Koyfman & Trevor 2014). The use of glucocorticoids is inappropriate or head trauma.
Upon attaining the desired ICP level, homeostasis suffices to be the next intervention. The objective of the intervention is to attain rapid anticoagulation reversal using warfarin. The intervention has proven to be effective in reducing mortality and haemorrhage progression for patients such as Cliffie that present intracranial haemorrhage (ICH). Before reversing anticoagulation, the trauma team should weigh the benefits of the exercise in comparison with the potential risks of the intervention to the individual. Possible actions include the use of frozen plasma (FFP), vitamin K, recombinant Factor VII (rfVIIa), and prothrombin complex concentrate (PCC). The team should administer 5-10mg of Vitamin K at an infusion rate of 1mg/min. The result of administering Vitamin K is to boost the production of clotting factors that prevent rebound coagulopathy following rfVIIa, FFP, or PCC (Koyfman & Trevor 2014).
There is an individualised dosage of FFP. In order to attain full reversal, a patient requires 10-15 mL/kg. The use of PCC dosage is also individualised. PCC contains factors II, VII, IX and X. The PCC volume required is less than that of FFP. The correction of INR occurs a few minutes following the administration of PCC. Upon using rfVIIa on Cliffie, the trauma team should be careful to avoid overdosing the patient since overdosing creates a thromboembolic event. Reversing the anti-clotting factor, heparin requires the use of 1 mg protamine sulphate per 100 units of heparin (Koyfman & Trevor 2014).
Improvements in the Management of Abdominal Injury
In order for any healthcare system to perform physical examination of intra-abdominal injury effectively, it is imperative that the facility should have the necessary capability. This is particularly important in cases such as Cliffie’s that may require the need for a surgical operation. The case does not mention shock assessment tests conducted on the patient with the use of a stethoscope and a BP cuff. Such tests are important in diagnosing the patient for shock. Rather than conducting physical examination of the patient, it is necessary for the trauma team to conduct supplementary examinations using ancillary diagnostic tests in the event that the abdominal examination of the patient is unreliable. An altered mental status of the patient such as loss of consciousness (LOC) at the time of occurrence of the trauma event compels members of the trauma team to perform supplementary abdominal tests on the patient (Jansen et al. 2008).
In the case of Cliffie, it was proper for the emergency team to perform the CT abdo-pelvis scan. The other supplementary tests include ultrasound scanning and the diagnostic peritoneal lavage (DPL). In the case of the trauma patient in the case, the presentation of the lesions yielded the need for an ultrasound test. It was proper for the trauma team to identify the need for the recommended test. The ultrasound (US) test will play a pivotal role towards diagnosing haemaperitoneum (Yilmaz et al. 2012). All hospital levels consider the test to be desirable. The reason behind the reduced utility of the test is its high cost. However, performing US test on Cliffie requires additional skills as compared to basic obstetric evaluation that is available in almost all emergency healthcare settings. The use of the CT scan on Cliffie added utility in the evaluation of the injured abdomen following the fall from the cliff and the stab. The CT scan is appropriate particularly in the case of retroperitoneal structures.
The origin of cystic lesions in Cliffie’s liver may be as a result of the trauma following the stab on the abdomen or increased pressure on the cystic fluid caused by the impact of falling down the cliff (Ereki & Saad 2015). The condition can result into anaphylaxis on the part of the patient or as well subject Cliffie to anaphylactic shock. In the event that the patient’s cyst ruptured into the bile canals due to the trauma, or following the release of the contents of the cyst in the circulating blood, the patient can succumb to anaphylactic shock (Erel et al. 2008). It is evident that timely surgery will play a pivotal role in dealing with Cliffie’s condition. The propensity of similar patients to develop allergic reactions necessitates immediate medical treatment for such reactions in Cliffie’s case.
There are complex treatment indications for patients such as Cliffie. Therefore, it is necessary for the trauma team handling Cliffie to weigh possible surgery against other available options of dealing with the condition. In the event that the lesions are complicated, surgery is the best option. If the US scan reveals that Cliffie has a ruptured cyst, it is apparent that the management of the condition will be more complex than that of a cyst that has not ruptured. In such a case, the surgeon will have to address the lesions in the liver as well as remove intra-abdominal protoscoleces. The goals of the surgical operation on the patient will be to minimise mortality, morbidity, and recurrence risks, prevent complications and remove the local disease (Griggs 2001; WHO 2009). Prior to intervening a ruptured cyst, the surgeon should irrigate the peritoneal cavity using adequate scolicidal agents prior to performing meticulous and careful removal of cystic contents. Some of the scolicidal agents encompass 10% providone-iodine, 0.5% silver nitrate, cetrimide-chlorhexidine, and 3%-30% hypertonic saline solution (Dirican et al. 2010).
In the event that Cliffie presents traumatic cyst rupture, the medical team should perform the surgery as soon as possible. The medical treatment should continue for a period of between 1 to 6 months considering the individual characteristics of the patient. Such treatment will be effective in reducing recurrence risk. The treatment of the patient will involve administering 10-15 mg/kg of Albendazole on a daily basis to the patient (Yilmaz et al. 2012). In the event that Cliffie presents a ruptured hydatid cyst, there should be an intensive post-operative follow-up exercise on the patient. These include indirect hemagglutination tests and ultrasonographic examinations that commence 6 months following the surgery. The patient will also repeat the follow-up tests every 1 to 2 years. However, the intervals of examining the patient will be shorter in the event that Cliffie presents ruptured cysts. Additional CT scans are necessary as follow-up measures to detect recurrence. The surgeon should be careful during the operation to deal with all cysts since it is possible to term forgotten cysts as recurrence.
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