Case 6
Ross Adams is a 17 year old football player in high school.While walking to the sideline, Ross took off his helmet andappeared confused. Falling to his knees, he began to vomit. Hecomplained of severe head pain, nausea, and vertigo. His coachcalled 911.
When the EMTs arrived, he was alert and oriented. The EMTs askedwhether he had fallen or been hit on the head, and he reported thathe was hit a couple times over the last couple days, but not in thelast few minutes. His skin was pale, cool, and moist. His pulse was54, regular, and strong. His respiration was 16, abnormal rhythm,shallow, and labored. His blood pressure was 157/102 mmHg. Hisright pupil was 5mm and nonreactive to light, and his left pupilwas 3mm and minimally reactive. Recognizing the signs of increasedintracranial pressure, the EMTs immediately transported him to thenearest emergency department.
Upon arrival at the emergency department, he vomited again. Hisblood pressure was 200/100 mmHg and his pulse was 48. His reflexeswere intact. A nurse administered mannitol 1g/kg rapidly byintravenous push.
A CT image of the brain revealed an acute 1.3 cm subduralhematoma in the left hemisphere. At this point, Ross becameunresponsive. He was taken to the operating room for an emergentcraniectomy and decompression.
Questions:
22.Which of the signs and symptoms indicated that Ross hadincreased intracranial pressure? For each, why?
23.Why did Ross’s blood pressure continue to rise?
24.Why was mannitol administered? What does it accomplish andhow does it work?
25.How does a subdural hematoma compare with an epiduralhematoma, a subarachnoid hemorrhage, or intracerebral hemorrhage interms of cause and manifestation?
Case 1
Cindy Brown is a 80 year old widow who was brought into theemergency room one evening by her brother. Early in the day, Mrs.Brown had seen bright red blood in her stool. She continued withher daily activities: she cleaned her house in the morning, hadlunch with her daughter, and volunteered at the local library.However, the bleeding continued all day, and she started feelinglight-headed. By dinnertime she decided to ask her brother forhelp. Mrs. Brown does not smoke or drink alcoholic beverages. Shetakes aspirin, as needed, for arthritis.
In the emergency room, Mrs. Brown is confused and anxious. Herskin is pale, cool, and moist. Her pulse is 116, regular, and weak.Her respirations are 22, regular, normal volume, and unlabored. Herblood pressure is 90/60 supine. The nurse takes a standing bloodpressure as well, and it is 75/45. Her hematocrit is 29%.
A colonoscopy shows that the bleeding came from a herniation inthe colonic wall. Mrs. Brown’s physician orders a normal salineinfusion, which the nurse starts, and a blood sample to be drawn tobe typed to prepare for a blood transfusion. Mrs. Brown receivestwo units of whole blood, and is admitted for observation. She isinstructed not to take aspirin.
Questions:
Describe the body’s sequence of events that led to Mrs. Brownbecoming light-headed and needing to seek help.
Discuss the physiological reason for each of the signs that youassessed (skin, pulse, respiration, blood pressure,hematocrit).
Discuss the rationale behind each of the treatments provided(normal saline, blood transfusion, no aspirin).
Had her blood loss been more severe, Mrs. Brown might havereceived a low dose of dopamine. Why is low-dose dopamine helpfulin the treatment of hypovolemic shock?
