A few quick questions about a patient i had

[MarioC]

My patient (46 male) was in a car crash (Restrained, Tbone). Head CT showed "atlanto-occipital and atlano-axial disassociation". I didn't have much of a chance to look at the CT myself due to the workload and if i had the time, its hard to convey exactly what i saw in text. While i was looking everything up at home, i came across an article where they said atlanto-occipital DISLOCATION is also considered internal decapitation.

First question is what's the difference between disassociation and dislocation. Different words usually have different meanings but in this case its hard to tell if disassociation is the medical term for dislocation. The one thing i have found about it, relates to pediatric atlanto-occipital disassociation and it has to do with ligament overextension.

Second question. He was running a dangerously high BP the whole day. Hospital history showed his BP was erratic from admission and even with a clonidine patch and PRN IV lopressor, there was very little change to it. was 157/102 @ 0800, 167/104 @1000, 167/103 @1100, 147/92 @ 1200. My question is, could this be related to the trauma (be it ICP or brain damage), related to history, or otherwise. I figure this one will be pretty hard to pin down since he was unable to give history and the hospital is in an area where people don't normally go to the doctor till they are coding. In otherwords, would head trauma cause a high BP or is history a much better possibility of origin.

Ill add more info as it is requested, but i honestly didnt get the chance to pull as much info as i want to (I dont think that's even possible. I always want more info.)and some of it wasn't available due to patient being nonverbal and unable to provide history.

Thank you again.

[JustBeachyNurse, LPN]

Look up autonomic dysreflexia as this is common with spinal cord trauma.

[Esme12, ASN, BSN, RN]

They are both severe injuries...complete separation is dislocation and yes ...is internal decapitation. Dislocation/subluxation is impartial and can vary in severity

- Discussion:

- more common children, since the pediatric occipital condyles are small and almost horizontal & lack inherent stability;

- this injury is usually but not invariably fatal 2nd to respiratory arrest caused by injury to the lower brain stem;

- caused by severe hyperextension Injury w/ distraction; ie being broadsided

- ligaments opposing occipital condyles to superior articulating facets of atlas (tectorial ligaments) are disrupted, resulting in either anterior translation (hyperflexion),

posterior translation (hyperextension), or longitudinal distraction;

- along w/ joint capsules, tectorial membrane is torn;

- dissociation may be complete (dislocation) or incomplete (subluxation);

- detection of this injury is difficult in cases of partial disruption or if reduction occurs after the initial subluxation

Atlantooccipital disassociation - Wheeless' Textbook of Orthopaedics

Occipital-Atlanto-Axial Injuries - Wheeless' Textbook of Orthopaedics

Automatic Dysreflexia (Hyperreflexia)

What is autonomic dysreflexia

[Here.I.Stand, BSN, RN]

Did the head CT show any cerebral edema or intracranial bleeding? If the brain is herniating, you'll see hypertension and then widening pulse pressure (greater difference between systolic and diastolic), with bradycardia. I'm guessing this isn't the case though, since either 1) they anticipated this coming based on elevated ICPs not responding to aggressive interventions, and the pt died or is dying or 2) his neuro exam suddenly declined and it becomes an emergent situation involving aggressive medical interventions, a run to head CT, and an emergent trip to the OR...or the pt died or is dying. Although personally I haven't seen a neurosurgeon offer the OR if the pt is herniating because the prognosis is so poor...not to say it's never happened, but in my experience I haven't seen it. My point with thoughts 1 & 2 is that one doesn't just herniate and hospital course continues unchanged. 3) his diastolics are also high.

My guesses would either be autonomic dysreflexia or chronic uncontrolled HTN which is just now being noted if he hasn't been seeing a provider.

[SierraBravo]

I agree with what Here.I.Stand said, when there is a subarachnoid hemorrhage, the patient can develop a Cushing Reflex whereby hypertension develops to maintain intracerebral perfusion (r/t high ICP), and then bradycardia follows. In terms of blood pressure, think about what drives the systolic and diastolic pressures. Systolic BP is driven by cardiac output (SVxHR). Diastolic BP is driven by norepinephrine. Obviously there are other factors which come into play, but I trust that pain is playing a part in his hypertension. A normal pulse pressure is around 40, so the fact that his pulse pressure is elevated certainly is consistent with elevated ICP's. I sure hope the patient is in a neuro ICU.