Identifying main medical problem...

uuuummmmmm...how about all of the above. The fall caused the head injury...that caused the epidural bleed...that then caused increased ICP...and now it sounds like he may be herniating.

Okay, seriously, what is his main promblem? I would say the increased ICP caused by the bleed. Yes, the initial insult was the head injury, but the epidural bleed is his main problem now. Fix the bleed and you fix the problem (hopefully).

BTW. How were his pupils? Babinski?

he had ipsilateral pupil dilatation...no info specifically on his babinski report, but i'm assuming because of the GCS Score of 5 (no eye opening, no verbal response, decorticate movement ot pain) that the babinski would be postive.

thanks.

#1 - Head injury cause by the fall, which caused the epi-dural bleed, which in turn most likely causes increased ICP-> possible shift-> AMS and motor defecites. Most if they get the bur hole in time, do great. It all depends on the length of time between neuro symptom onset and releif of increased ICP (i.e. evacuation of the hematoma)

If he had not come into the ER, and been seen with a GCS of 15, the #2 possibility would have been a factor also.

#2 - The epidural hematoma, was existant prior to the fall. As the ICP increased secondary to the bleed -> increased ICP, the patient then had AMS with other neuro defecites. This then caused the patient to fall down.

One of the down sides or tauma and neuro injuries, or MI's, diabetes, CVA's, TIA's etc, is that there is no way to find out what came first the chicken or the egg?

However, in your case #1 clearly applies!!!

:-) ?

Going off on a tangent:

When you see a patient go comatose (GCS falls to a 5) like that, what should you do? I'm already assuming that ABCD has already been assessed as an inital assessment when the patient came to the ER, would you redo this assessment then to compare? Or just prep b/c the patient will most likely have to go to the OR?

Going off on a tangent:

When you see a patient go comatose (GCS falls to a 5) like that, what should you do? I'm already assuming that ABCD has already been assessed as an inital assessment when the patient came to the ER, would you redo this assessment then to compare? Or just prep b/c the patient will most likely have to go to the OR?

If their GCS drops to a 5, they have, or will soon have, a serious problem with "A" & "B" of the ABCs, i.e. they will need assist with maintaining the airway & ventilating. C-collar (if c-spine injury cannot be ruled out). Intubate. That way you can also maintain the PaCO2 (measured indirectly via PetCO2) at desired level. Give Mannitol if indicated (intraparenchymal bleed/injury). Be judicious w/ crystalloids but ensure mean pressure sustains blood flow to brain . Maintain head in neutral position and keep HOB up to 20-30 degrees (if feasible). NG/Foley/Temp probe if time allows. Get them to OR ASAP.

Basically you stablize the best you can until you can get them to the OR/ICU.

I go cause and effect at this point, head trauma is your main because it can lead to more than just high ICP , and even the ICP will go into more issues....

Think of it as a ladder...go from reason it is there at ground level (cause) and what happens as you go on or up (effects of placing ladder) ....that always helped me...goal being taking the steps to get back to ground level (or baseline). I don't know..works for me....

You will want to assess this patients neuro status every hour. A CT scan will be ordered. Definitely prep for the OR, but some bleeds can't be fixed with surgery. In that case you will want to do everything possible to prevent increased ICPs by giving mannitol. You will also want to maintain blood pressure to keep the ICPs down and CPPs up. May need to give pentothal as well. Most likely patient will be intubated. Blood gases should be done every 4 hours to keep the PaCo2 at the ordered levels. Keeping the temperature of the patient low may be ordered. I have seen doctors orders to maintain patient's temperature between 95-96 degrees F. A bolt might be placed to monitor ICPs and CPPs. So you will need to gather equpiment for the bolt placement.