Case study...

  1. 6
    So this isn't a specific case study nor does it come from a single patient... it's an amalgamation of cases with a bit of poetic license tossed in... but it may still be helpful...

    Please, experienced nurses, forgo the urge to post before the learners have the opportunity... by all means, though, chime in to respond to them (and to correct me as needed).

    Here's the scenario...

    Pt found down on the sidewalk by EMS... No hpi available... GCS=5 on their arrival, improves to GCS=12 by arrival to ED...

    Pt is a 30-something, well-developed male... uncooperative but not combative... strong odor of alcohol... vitals are WNL, FSBG=120...

    We have venous access, airway is intact, PERLA 4 but sluggish, moderate hematoma R occiput...

    Basic trauma labs have been drawn...

    Docs say, "we need to get him to the scanner...", what do you say/do... Questions, thoughts, concerns?
    Joe V, Carpediem1012, kelleytison, and 3 others like this.
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  4. 30 Comments so far...

  5. 5
    Had that guy tonight.....
  6. 3
    Ha me too. Mine was alert enough to urinate all over the cabinets and floor of my ambulance. I really hate dealing with intoxicated patients who are buttholes. Oh how I yearn to get out of ems.
  7. 1
    "Amalgamation"...such a great word, and it rarely is used

    Was pt actually drinking? I'm not sure if "strong odor of alcohol" means he in general reeks of etoh or patient-opened-mouth-to-exhale-and-curled-my-hair. Would you do a second FS? (I may be totally over thinking this) 30-something, well-built is unlikely to be a type 2 diabetic but could be a type 1 with BG on the downslide, which could be bad if he's in scanner and BG tanks (again, may be over-thinking this)

    Can the increase in GCS be indicative of epidural bleed? Frequent reassessment (GCS) to see if there is change in neuro status. I am thinking that with any head trauma there must be a "hope for the best but plan for the worst" way of thinking.

    Looking forward to responses on this thread
    SeattleJess likes this.
  8. 3
    Quote from Jayjormom
    Ha me too. Mine was alert enough to urinate all over the cabinets and floor of my ambulance. I really hate dealing with intoxicated patients who are buttholes. Oh how I yearn to get out of ems.
    Yes well...remember where EMS brings them...to the emergency room. You will still have to deal with them...except they will be detoxing and even more unpleasant. ((HUGS))
    Everline, SeattleJess, and chare like this.
  9. 3
    Quote from smf0903
    "Amalgamation"...such a great word, and it rarely is used

    Was pt actually drinking? I'm not sure if "strong odor of alcohol" means he in general reeks of etoh or patient-opened-mouth-to-exhale-and-curled-my-hair. Would you do a second FS? (I may be totally over thinking this) 30-something, well-built is unlikely to be a type 2 diabetic but could be a type 1 with BG on the downslide, which could be bad if he's in scanner and BG tanks (again, may be over-thinking this)

    Can the increase in GCS be indicative of epidural bleed? Frequent reassessment (GCS) to see if there is change in neuro status. I am thinking that with any head trauma there must be a "hope for the best but plan for the worst" way of thinking.

    Looking forward to responses on this thread
    There are keys to your concerns. ANY patient that is altered you check the blood glucose. Why are you concerned about blood glucose in someone who had alcoholism?

    There are keys in the scenario...
    Pt found down on the sidewalk by EMS... No hpi available... GCS=5 on their arrival, improves to GCS=12 by arrival to ED...

    Pt is a 30-something, well-developed male... uncooperative but not combative... strong odor of alcohol... vitals are WNL, FSBG=120...

    We have venous access, airway is intact, PERLA 4 but sluggish, moderate hematoma R occiput...
    Why would you be concerned about a hematoma in the occiput region.
  10. 3
    So the guy's clearly at risk for a TBI... also at (low-but-not-zero) risk for c-spine injury... also, without knowing HPI, abdominal trauma cannot be ruled out... docs want to get a CT STAT.

    Problem is, you've got a uncooperative drunk dude... will you be able to get a CT if he won't hold still? Then there's the issue of him sitting up and falling/rolling off the CT table...

    This patient isn't safe to go to CT... nor will the CT be effective anyway... gotta hold still... newbie docs aren't so cognizant of simple risks like this.

    So, give him some sleepy meds... a whiff of ativan, a pinch of haldol, and a bit of fentanyl... guy is pretty still now... probably is safe to go to CT... probably... sometimes they're nighty-night right up until you start sliding them to the table... then up they come. Also, sleepy meds and booze... and possible TBI... airway is a risk... but not to the level of intubation... but needs O's... NR was in place at 15L... (pre-ox in case he needs to be tubed... and help him out since he's a little sonorous at times).

    So, think through how you get this guy safely to CT and back again... could wake up and start resisting... needs the mask left in place... apparently drunk as a skunk... Needs a CT head, CT spine, CT/contrast abd/pelvis...

    You're the nurse... you're doing the transport... what should you be thinking about? What do you need with you? What precautions should you take?
    emtb2rn, Esme12, and SeattleJess like this.
  11. 4
    [QUOTE=Esme12;8008663]There are keys to your concerns. ANY patient that is altered you check the blood glucose. Why are you concerned about blood glucose in someone who had alcoholism?

    There are keys in the scenario...Why would you be concerned about a hematoma in the occiput region.[/
    QUOTE]

    BG concern would be because the liver is dealing with the etoh and not putting out glycogen/glucose to keep BG from getting too low.

    I think the hematoma in occiput region would be of concern because it's pretty darn close to the goodies of the brain...swelling at occipital region could push on cerebellum which could push on brainstem and interfere with respiration, HR, etc. If the swelling is bad enough, couldn't the brain herniate through the foramen ovale? I don't know if the path of least resistance is inward toward middle of brain or downward toward cerebellum and spine?

    You're the nurse... you're doing the transport... what should you be thinking about? What do you need with you? What precautions should you take?

    As for transport of patient, hmm...well I would be thinking of my "what if" he gets rowdy on the table/during transport, I'm not sure what (or if there is a) protocol is for this: Are you able to take sleepytime "just in case" meds with you (since he already has a line in)?? Is restraint an option?? (I hate throwing restraint in there because it has been drilled and drilled and drilled into us that restraints are absolute last resort...plus I would think a drunk guy coming to while he's strapped down would not equate to quiet and cooperative).

    I would definitely have PPE stuff with me since drunk=spewing bodily fluids. Aspiration would be a concern for patient. I'd have something for him to throw up in as well.
    phaniea69, emtb2rn, Esme12, and 1 other like this.
  12. 2
    Pretty good. This guy was found face down with a o=would to the back of the head. Did someone hit him?. YOU think C-spine. YOu see a hematoma in the occipital region you think possible brain bleed and basilar skull fracture. What do you look for in a basilar skull fracture.

    You are right about the brain and vitals functions on the brain stem.

    IN transporting you always think airway...have an ambu bag. Oxygenation...Non re-breather. If the patient had sedation to chill hi out I would ask for a PRN to carry with in my pocket. I would also carry narcan and/or mazicon just in case everything caught up with the patient. I would have soft wrists just in case. A pulse ox and a monitor are a must.
    Everline and ♪♫ in my ♥ like this.
  13. 1
    Quote from Esme12
    Pretty good. This guy was found face down with a o=would to the back of the head. Did someone hit him?. YOU think C-spine. YOu see a hematoma in the occipital region you think possible brain bleed and basilar skull fracture. What do you look for in a basilar skull fracture.

    You are right about the brain and vitals functions on the brain stem.

    IN transporting you always think airway...have an ambu bag. Oxygenation...Non re-breather. If the patient had sedation to chill hi out I would ask for a PRN to carry with in my pocket. I would also carry narcan and/or mazicon just in case everything caught up with the patient. I would have soft wrists just in case. A pulse ox and a monitor are a must.
    Battle's sign (raccoon bruising) and test any possible CSF for halo?
    Esme12 likes this.


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