Traumatic Brain Injury Case Studies

1
Traumatic Brain InjuryCase Studies
2
Case Study 1
3

• 16 year old male, jumping from bridge, slipped
  and struck head on railing before hitting the
  water.
• Came up above water, but appears dazed and slow
  to respond to questions.
• His mother brings him to the local emergency
  department.

4

• On your initial assessment, he is amnestic to the
  events surrounding his injury, oriented to
  person, place and time, and is complaining that
  the back of my head hurts. The rest of his exam
  is unremarkable.

5
Does this patient require a head CT?

1. Yes
2. No

6
(No Transcript)
7
This Head CT Shows

• 1. Epidural Hematoma
• 2. Subdural Hematoma
• 3. Subarachnoid Hemorrhage
• 4. Shear injury
• 5. No acute injury

8
Based on his physical exam, mental status and
head CT results, he should

• Have another CT scan in 6 hours
• Be discharged to home with his mother
• Be admitted to the Trauma Service for at least
  24 hours
• Spend the night in the Emergency Department

9
As you are preparing his discharge paperwork, he
says, GOOD! I have football practice tomorrow!
Can he play?

1. Yes
2. No

10
When can he return to football?

• A. When he says he feels fine
• B. When his mother thinks he is well enough to
  play
• C. After further evaluation demonstrates that he
  is no longer suffering from post concussive
  symptoms.

11
Case Study 2

• 75 year old woman, tripped over dog, striking
  head on floor. She sustained a brief loss of
  consciousness, prior to waking up with her
  daughter at her side.

12

• Daughter transports her to local Emergency
  Department.
• She is awake and alert, and complains of the
  worst headache of my life
• She is evaluated by the ED staff, who call you
  once they see her head CT

13
(No Transcript)
14
This Head CT shows

• A. Epidural Hematoma
• B. Subdural Hemorrhage
• C. Subarachnoid Hemorrhage
• D. SAH EDH
• E. SDH EDH
• F. No acute injury

15
Epidural Hematomas are often associated with

• Cervical spine fractures
• Parietal skull fractures
• C. the worst headache of my life
• D. Venous bleeding

16
Subarachnoid hemorrhages frequently

• A. Require surgical evacuation
• B. Produce the worse headache of my life
• C. Produce significant mass effect
• D. A C
• E. All of the above
• F. None of the above

17
She is admitted to the trauma service,
hemodynamically stable and in no acute
distress.Your two main goals of care in the
immediate future?

1. Get her a diet and a blanket
2. Consult PT and OT
3. Prevent hypoxia and hypovolemia
4. Contact case management and arrange for transfer
   to skilled nursing facility

18
Does she require a repeat Head CT?

1. Yes
2. No

19
Case Study 3

• 22 year old man s/p single vehicle MVC vs. tree.
  EMS finds him unresponsive (GCS 3). He is
  intubated without drugs, IV access is initiated
  and he is transported to the ED for evaluation.
• Trauma evaluation notes a right forearm
  deformity, and scattered abrasions.
• Prior to admission to the Trauma Service, he is
  taken through the CT scanner

20
(No Transcript)
21
This Head CT shows

• Epidural Hematoma
• Subdural Hematoma
• Subarachnoid Hemorrhage
• Shear injury
• 5.No acute injury

22
Your two main goals during his resuscitation are
to prevent ________ and ________.

1. Pressure ulcers, contractures
2. Family arguments, disagreements
3. Hypoxia, hypovolemia
4. Pain, discomfort

23

• He has an ICP monitor placed, with ICPs ranging
  8-10.
• He remains hemodynamically stable, and is cleared
  to have his forearm repaired by the Orthopaedic
  service.
• On Hospital Day 4, he is trached and PEGd, and
  weaned from the ventilator by hospital day 5.
• His ICP monitor is discontinued.

24
His family asks you, When will he wake up?

1. He may never wake up
2. The longer he remains comatose, the less likely
   it is for him to wake up
3. If he wakes up, he will likely emerge through
   several phases of the RLA scoring system.
4. It will take up to a year to determine his long
   term, new normal, baseline.
5. All of the above
6. None of the above

25
Speech Therapy is consulted for a cognitive
evaluation. They report that he is functioning
at a RLA II level. You can expect him to have

• No response
• Confusion with agitation
• Generalized responses
• Confusion without agitation
• Appropriate responses

26
He progresses to a RLA III (localized response)
emerging IV (confused, agitated). PT and OT come
to evaluate him.You anticipate they will
recommend

1. Skilled Nursing Facility
2. Inpatient Rehabilitation
3. Home with Family
4. LTAC