Critical Thinking Snapshot II - page 2
like the thread started by betts this will be an exercise in critical thinking and clinical assessment/decision making. what i will do here is relate day by day a patient story. each time i post i... Read More
May 22, '03<< 0700 The police inform the nursing staff the mechanism of injury. He was thrown head first into a brick wall.>>
Nice of them to make that revelation, when the guy is on his deathbed.
May 22, '03Doesn"t the Glasgow Coma Score total 15, not 14? Or is there a different one used in your hospital?
Glasgow Coma Score
The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below :
Best Eye Response. (4)
No eye opening.
Eye opening to pain.
Eye opening to verbal command.
Eyes open spontaneously.
Best Verbal Response. (5)
No verbal response
Best Motor Response. (6)
No motor response.
Extension to pain.
Flexion to pain.
Withdrawal from pain.
Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11.
A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.
Teasdale G., Jennett B., LANCET (ii) 81-83, 1974.
May 22, '03Sammysue - although a GCS is often out of 15 some hospitals use an adapted number 14. The section left out is withdrawal the reason it is left out of some coma scores is that it is considered difficult to truly distinguish between withdrawal and abnormal flexion.( Lindsay Bone and Callander 1997) One of the problems with the coma score is this variance between facilities. Here in Australia we even have the "Adelaide childrens score" which adapts the standard GCS for children under three. This makes it vitally important to tell the person not only what the score is but what referrence renge you are using.
Sanakruz - one of the reasons why I remember this case so vividly is that I was working at the recieving hospital. We got him too late - he was brain dead from an epidural haematoma. Sad outcome not only for him and his family but the guy who caused the injury as he was subsequently charged with murder not manslaughter or GBH. Such is the law here.
The lessons to be "learnt" from this tale are
A) the importance of trying to ascertain the mechanism of the injury. - I feel sure that anyone who heard HOW he hit his head would have been MORE vigilant and MORE suspicious about adverse outcome and
B) Although he was intoxicated at the time of the injury he sould have become more compliant and more rational as time went on and the alcohol was metabolised from his system. As you can see it was 5 hours after admission and he had not improved his GCS from admission. This should have sent warning bells. But as I stated hindsight is 100% correct.
Even our neurosurgeon kept saying - if they had done burr holes even when his pupil blew they could have saved him. We will never know. It was a small country hospital and epidural bleeds are notorious for "fooling" the staff.Last edit by gwenith on May 23, '03
May 23, '03At a small hospital drilling burr holes would be about as safe as taking a mallet and chisel to his head. I don't think our hospital has the equipment to do it, and definitely know that nursing has no idea what to do with the holes afterwards. He was unchanged at 0430, I think our hospital wouldn't have done anything until 0500 either. I would also account for his lack of improvement CNS wise with the fact that it was the middle of the night, he was sleepy and didn't want to wake up for that @#$% nurses asking stupid questions. Would definitely be concerned if he was getting worse though. Even if they had known the mechanism of injury do you think they would have transported him sooner?
May 23, '03It is one of those cases where we will never know. Classically an epidural or as some texts call it an extradural bleed has a "talk and die " pattern but this only occurs in approx 1/3 of cases (texts vary with the percentage quoted) It is more common for the patient to be admitted with a decreased level of consciousness that either does not improve or deteriorates over time. These are most commonly an acute phenomena occuring within minutes to hours of the initial injury. It is possible ot perform Burr holes in a rural setting but as canoehead pointed out it is far from ideal. These are the cases you pray you don't get in a rural hospital.
May 23, '03Canoehead - Sorry but I forgot you were also in a rural hospital.
Here is the website for the Australian Neurosurgical Society it has a booklet available free that has been written for Australian rural and remote area medicine and nursing.
Hope this helps all of my colleagues working in rural and remote areas - my hat, as always, is off to you,,,,,,,,,,,,,,,,,