Paramedics
When the ambulance arrived, Zac had a GCS of 15 and could recall the whole incident. Zac appeared to have no other injuries. The paramedics undertook vital signs which they stated were ‘normal’ and applied a bandage to Zac’s head wound. The security guard stated that he ‘didn’t think Zac lost consciousness’.
Triage
- 18 year old male, brought in by ambulance following an alleged altercation where patient struck head on road curb at 2300 hrs.
- Patient is denies loss of consciousness but unable to recall all events. Patient appears alert but teary and takes a couple of moments to answer questions.
- On examination, 4cm occipital laceration noted with slow ooze from wound. Dressing insitu. Vital signs and GCS recorded at 2325 hrs as per chart. No other obvious injuries.
- Patient denies drug use, states has had approximately ‘five beers since 7pm’. Breath alcohol taken at 2330 hours 0.06%.
- Patient reports pain to be 5/10 at occipital region, no analgesia taken prior to presentation.
- Patient states is usually fit and well.
Past medical history
Childhood asthma, up-to-date with immunisations (last tetanus 12 months ago).
Not on any medications and no known allergies.
Assessment and investigation data
Vital signs
- Respiratory Rate: 17 breaths/minute
- SpO2: 99% on room air
- Blood Pressure: 141/88 mmHg
- Heart Rate: 90 beats/minute
Neurological observations
GCS:
Pupillary response - bilateral 4+
Limb strength - bilateral, upper and lower limbs: normal power
CT report
Exam Information
Modality: CT
Body Part: NEURO
Description: CT Brain and C-Spine
Performed Date: 25/3/Year Time: 0015
Final Report
CT BRAIN AND C-SPINE
CLINICAL NOTES:
Witnessed awkward fall after physical altercation, head knock with no reported loss of consciousness
Findings:
A non- contrast CT has been acquired.
No acute intracranial abnormality is seen.
There is no intra or extra-axial haemorrhage noted.
There is no cerebral oedema, midline shift or hydrocephalus.
Unremarkable posterior fossa structures.
No skull fractures are seen.
No obvious fractures from C1 to T2.
IMPRESSION:
No acute abnormality on the examination.
Other
Zac complains that his hand is hurting.
Medical Review - soft tissue injury from extending his hand to break his fall.
Actions and interventions
Interventions
The decision is made to keep Zac in hospital overnight, for observation.
Paracetamol is charted for pain. No other medications are charted.
Vital signs and neurological observations to be undertaken hourly.
At 7.00
You are the nurse who is allocated to care for Zac. You review all Zac's documentation and go to attend his observations at 0700.
You gather the following data:
Vital signs:
- RR: 18 breaths/minute
- Sp02: 98%
- BP: 146/98 mmHg
- Pulse: 106 bpm
- Temp: 37.3oC
- Pain: he mumbles that his "head is hurting", but cannot rate the pain; he is holding his head with his hands
Neurological Assessment:
- Best Eye Response: Eye opening to verbal stimuli
- Best Verbal Response: Confused
- Best Motor Response: Obeys commands - slow to respond
- Pupils: Right - size 3 mm, sluggish reaction; Left - size 3 mm, sluggish reaction
- Limb Movements: Right arm - mild weakness, Left arm - normal power; Bilateral legs - normal power
Question:
If Zac deteriorates further, hypertonic saline may be administered. Explain the rationale if this therapy were to be used in Zac's care, and the changes in parameters (or lack thereof) that would be evidence that the intervention is having the desired effect. You should also explain why administration of this therapy to Zac should proceed with caution.