ZEN PRESENTATION

A NEUROLOGICAL CASE STUDY

LARRY

Larry is a 28-year-old male who was thrown from his motorcycle after being hit by the car he cut off on I-77. Larry is from South Carolina and not wearing a helmet at the time of the crash. His head hit the pavement when thrown from the motorcycle and he skidded 10 feet on his face and anterior body until coming to a stop. He was unconcious when EMS arrived.

MEET LARRY

If Larry has a head injury, would it be a primary or secondary injury?

What type of TBI would you suspect to have occurred?

Larry is taken to the nearest trauma center. He regains consciousness in the ambulance on the way to the hospital. He was unconscious for at least 45 minutes.

What signs and symptoms would you anticipate seeing in Larry?

Larry is confused and agitated when he arrives to the ED. He complains of :my head being crushed by giant's hands." His speech is slurred. He knows his name, but cannot tell you the month or year. He keeps telling you that he's going to work. Suddenly, Larry projectile vomits and begins to seize.

What nursing interventions should be done at this time?

Because of the sequence of events, what is Larry in danger of?

After the seizure, you do a full neurological exam on Larry. As you begin, you notice his left pupil is larger than the right pupil and both are sluggish to light. You also notice that he is pulling his arms toward the center of his body. Larry is emergently intubated.

Why was Larry intubated?

What are your priority actions?

What type of posturing do you notice in Larry?

The head CT shows a large epidural hematoma. The neurosurgeon on call comes int the unit seconds after Larry arrives back from CT scan.

What do you expect the neurosurgeon to do?

What do you suspect is going on with Larry due to the bleed?

The neurosurgeon drills burr holes into Larry's skull. A ventriculostomy drain is also placed for ICP monitoring and the drainage of blood. Larry's ICP is 18. His blood pressure is 85/40.

What interventions would you begin for Larry now?

What is Larry's CPP? Based on this finding, is Larry perfusing his organs adequately?

Is Larry's ICP within the normal range?

Larry's ex-wife comes in to laugh at Larry's misfortune (she never liked the motorcycle). You notice that Larry's ICP increases to 25.