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Case Study #72:

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Katie Geraghty

on 3 April 2014

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Transcript of Case Study #72:

Case Study #72: Subdural Hematoma
Katherine Geraghty
Scenario
"K.B. is a 21 year-old man with a past medical history of seizure disorder controlled with Tegretol. He was accidentally struck in the head by a pitched baseball while batting. He was unconscious momentarily, about 5 seconds, then awakened and was alert and responsive. After a few hours, K.B. returned home with complaints of a "splitting headache", drowsiness, slight confusion, and some nausea. K.B. was taken to the local hospital ED where a CT scan revealed a left subdural hematoma. He has been transferred to your medical center which has a neurosurgeon on call. "
K.B. is a 21 year-old man with a past medical history of
seizure disorder
controlled with Tegretol. He was accidentally struck in the head by a pitched baseball while batting. He was
unconscious
momentarily, about 5 seconds, then awakened and was alert and responsive. After a few hours, K.B. returned home with complaints of a "
splitting headache
",
drowsiness
, slight

confusion
, and some
nausea
. K.B. was taken to the local hospital ED where a CT scan revealed a left
subdural hematoma
. He has been transferred to your medical center which has a neurosurgeon on call.
The ED RN gives you the previous information during a phoned report. What other information do you need to prepare for K.B.?
You have not taken care of a patient with a head injury recently. You look up subdural hematoma. What do you find?
K.B's Subdural hematoma is considered acute because symptoms have appeared within 24 to 48 hours of injury. What are the other two classifications of subdural hematoma?
Acute
Subacute
Chronic
What are the common signs and symptoms of an acute subdural hematoma?
Why are older patients and alcoholic patients at risk for chronic subdural hematomas?
What neurological changes and indicators would you monitor in K.B. for increased ICP?
Why is it important to make sure K.B. is taking his Tegretol and has a therapeutic sodium level?
The decision was made in K.B.'s case not to do a Craniotomy. When would a neurosurgeon decide to treat medically versus preform surgery?
The resident writes an order for D5W to infuse at 125 ml/hr. Does this order concern you and if so, why?
How would you instruct the NAP to position K.B. in bed to help control ICP?
What other interventions would be appropriate to implement while caring for K.B. that would assist in reducing venous volume?
You go in to assess K.B. and find that he is complaining of a headache. His heart rate is 120 and his blood pressure is 90/60. His urine output for the past hour was 685 mL with a specific gravity of 1.002. What do you immediately suspect is occurring?
Using SBAR what information would you like to provide to the neurosurgeon when you call?
What do you anticipate the care of K.B. will include over the next 2-3 hours?
How would you support the family?
"Meningeal hemorrhage resulting from accumulation of blood in the subdural space"
Blunt impact to the skull causes veins in the cerebral cortex to tear and bleed, which causes separation of the arachnoid and the dura
5 to 22% of severe head injury
1 -5 out of 100,00 people yearly
most common in older males (3:1)
Bilateral in infants
leads to neuro impairment, infection, seizure, coma, death
increased ICP
Blunt impact, coagulation medication
Less than 72 hours after injury
Separation of arachnoid and dura
Increased ICP
Emergency Surgery
Slowly, overtime - more than 21 days
space fills with CSF
New vessels grow and burst
More common 60+ years
Alcoholism, Epilepsy, Coagulopathy, Arachnoid cyst, Cardiovascular disease (HTN), Diabetes

between 3 and 21 days
least common
not much information
symptoms take longer
Pupil irregularity
Decerebrate posturing/flaccidity
Visual changes, double vision
Decreased level of consciousness
Headache
Difficulty with gait or balance
Cognitive dysfunction or memory loss
Personality change
Aphasia
Vomiting
Confusion
Increased blood pressure
Seizures
Unconsciousness

"Alcoholics are prone to thrombocytopenia, prolonged bleeding times, and blunt head trauma."

Elderly have a higher incidence of CVD and HTN, prone to bleeding, vessels weaker
Many patients with acute subdural hematomas are given antiseizure medicationsto prevent possiblity of seizure which would increase the ICP. Because he has a known seizure disorder his risk would be higher.

Sodium is very important in osmotic therapy to reduce ICP. Subdural Hematomas are a known cause of hyponatrima although it is not really well understood. SAIDH?
Decrease ICP before surgery
Not big enough or has stopped bleeding
Patient is stable and conscious
Decrease risk of infection
Monitor and repeat CT scans
"Hypertonic saline (3% NS) has osmotic, hemodynamic, vasoregulatory and immunomodulatory effects. Reduces osmolar swelling by decreasing both intra-cellular and
interstitial fluid volume. It also improves and maintains intravascular volume and blood pressure." (5)

Extracts fluid from the cells and the brain to decrease ICP
D5W is a hypotonic solution that would only increase swelling in the brain and ICP - Contraindicated
Head of Bed 30 - 45
Improve cerebral drainage
Lower ICP and CBV
Disease and Conditions: Subdural Hematoma, Lippincotts Docucare. February 17, 2014. From http://lnareference.wkhpe.com/

Meagher, Richard J (2013 March 1). Subdural Hematoma Treatment and Management. Medscape. February 17, 2014. From www.Medscape.com

Intracranial Hemorrhage. The Mayo Clinic. February 17, 2014. From www.mayoclinic.org

Karriem-Norwood, Varnada. (2012, August 31) Subdural Hematoma. Webmd Brain and Nervous System Health Center. February 17, 2014. From www.webmd.com

Franzon, D. (2013) MANAGEMENT OF HEAD INJURY & INTRACRANIAL PRESSURE. Standford University. February 17, 2014, From peds.stanford.edu

Case Study From: Winningham's Critical Thinking Cases in Nursing 5th edition, 2013
Glasgow Coma Scale
Breathing on his own?
Vitals (Fever!)
LOC

Medications
Lab results?
Fluid and Electrolytes
Support System
Changes in LOC
Worsening of Symptoms
Increased drowsiness
Cushings Triad
Widening pulse pressures
Bradycardia
Irregular breathing
Updates
Course of treatment
Limitations
Explanation of condition
CPP
MAP
ICP
Increase MAP to compensate for an increasing ICP.
-Provide fluids, vasoconstrict

Decreased MAP from Vasodilation leads to hypoxia, hypotension, increased ICP, seizures, fever, hyperglycemia
Brain (80%) -
Dehydrate with 3% NS or Mannitol
CSF (10%) -
Drainage with EVD
Blood Volume (10%) -
Hyperventilation
Decreased CO2 causes vessels to constrict

Increase volume in skull (surgery)

1) Avoid hypoxia and hypotension
Supplemental O2 or intubate
Achieve euvolemia
Support BP to maintain CPP
2) Avoid Fever
3) Intubate/sedate
4) Mild hyperventilation
Keep PaCO2 normal 35mmHg-40mmHg
5) Ventricular Drainage
6) Osmolar therapy to achieve serum Osm 320
Mannitol (0.25 to 0.5 g/kg)
Hypertonic saline (5 ml/kg of 3%NS) may be given as bolus or
continuous 3% infusion checking sodium frequently
7) More aggressive hyperventilation - PaCO2 (28-32 mmHg)
Refractory ICP—acute short term therapy
8) Barbiturates
decrease cerebral metabolic rate and lower CBV and ICP
9) Induce Hypothermia
10) Repeat CT scans
11) Decompressive craniectomy
Increasing ICP and decreasing CPP
Brain bleed increasing in size
Involves the pituitary gland
Diabetes insipidus
Full transcript