Neurologic Diseases Case Study Analysis
Case study 1
Two individuals come to the emergency department with head injuries. One, 25 years old, has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The other, 65 years old, has increasing confusion after a fall that happened earlier in the week.
A hematoma is a collection of blood outside a blood vessel. An extradural hematoma occurs when a blood vessel is injured, and blood accumulates in the extradural space between the dura and the skull. It is mostly caused by a blunt force head trauma that results in a linear skull fracture with minimal or no displacement. In most cases, the hemorrhage is a result of laceration or rupture of the middle meningeal artery. The accumulated blood does not cross the suture lines as there is a tight adherence of the dura to the calvarium. The high pressure from the arterial blood causes the dura matter to separate from the skull, creating a hematoma with an elliptical appearance. At the time of injury, the patient can have a momentary loss of consciousness followed by an interval of apparent recovery, known as a lucid interval. With continued bleeding and blood accumulation, the patient gets a severe headache and their mental status declines due to intracranial pressure rise (Hinkle & Cheever, 2018).
A subdural hematoma, on the other hand, is a collection of blood between the dura and the brain, a space that is normally occupied by a thin cushion of fluid. It is mostly venous in origin and occurs after the small blood vessels that bridge the subdural space rupture. High-speed impact to the skull, which may be caused by sudden changes in velocity is the most common mechanism that leads to the development of subdural hematomas. Subdural hematomas can also result from coagulopathies, trauma, or rapture of an aneurysm, that causes tearing of bridging veins leading to venous blood accumulation in the subdural space. It crosses suture lines and has a crescent shape appearance (Hinkle & Cheever, 2018).
The patient requiring immediate surgical intervention is the sixty-five-year-old patient with increasing confusion after a fall. The increasing confusion implies that the patient may be having a hematoma that is gradually increasing in size. Emergency surgical intervention is needed to decrease the intracranial pressure, remove the clot and control the bleeding. It will manage the patients confusion and prevent exacerbation of the patients condition (Dash & Chavali, 2018).
Case study 2
A 38-year-old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone pole instead. His head hit the windshield, and he suffered severe head trauma.
The patient most likely suffered a contusion. A contusion is a type of closed head injury. It is a severe injury in which the brain is bruised, with possible surface hemorrhage from small blood vessels leaking into the brain tissue. A contusion typically results from a direct impact on the head. The brain strikes a ridge in the skull when the head moves suddenly or hits a solid object with great force. For instance, in a car accident, a contusion can result when the driver hits their head on fixed objects, like the windscreen, windows, or the steering wheel (Fernandes et al., 2018). Signs and symptoms of a cerebral contusion are unconsciousness, faint pulse, shallow respirations, cool pale skin, dizziness, severe headache, nausea and vomiting, confusion, drowsiness, restlessness, irritability, memory loss, dilated pupils, and difficult balancing or coordination (Hinkle & Cheever, 2018).
Several investigations should be done to guide the patients treatment. A Glasgow Coma Scale score should be done to assess the severity of the brain injury. Imaging tests are done to establish the location, type, and extend of the injury. They include a head computerized tomography (CT) scan that provides a detailed view of the brain and surrounding structures, visualizing any fractures, brain tissue swelling, hemorrhage, or hematomas. Magnetic resonance imaging (MRI) can also be done to create a detailed view of the brain. An intracranial pressure monitor can be used to monitor the patients intracranial pressure (Vella et al., 2017).
A blood sample should be taken for arterial blood gas analysis. The blood pressure, carbon dioxide, and oxygen levels should be kept at desirable levels to avoid secondary brain injury. The patient can be given supplemental oxygen through a face mask or mechanical ventilation. The patients level of consciousness should be monitored to establish the patients prognosis. Analgesics like opioids are given to relieve the patient of pain. Sedation may be done to reduce muscle activity, mitigate response to pain and prevent an increase in intracranial pressure. If the patient has a fever, antipyretics are given. Anticonvulsants like phenytoin are administered if seizures occur. Osmotic diuretics like mannitol are given intravenously to lower intracranial pressure and maintain serum osmolality. Other diuretics like furosemide can be used. Emergency surgery should be done to stop any bleeding in the brain, remove any hematomas, and lower intracranial pressure. It minimizes additional damage to the brain tissues. The patient may require close monitoring in an intensive care unit (Dash & Chavali, 2018).
References
Dash, H. H., & Chavali, S. (2018). Management of traumatic brain injury patients.Korean Journal of anesthesiology,71(1), 12. doi:
Fernandes, F. A., de Sousa, R. J. A., & Ptak, M. (2018).Head injury simulation in road traffic accidents. Cham: Springer International Publishing.
Hinkle, J. L., & Cheever, K. H. (2018).Brunner and Suddarths textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd.
Vella, M. A., Crandall, M. L., & Patel, M. B. (2017). Acute management of traumatic brain injury.Surgical Clinics,97(5), 1015-1030.
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