Fall during a fishing weekend

Problem 42 Fall during a fishing weekend



Andrew Zacest




A 43-year-old man has been brought by ambulance to the emergency department at the weekend. He had been on a fishing trip on a boat with his friends drinking alcohol and he had reportedly taken Ecstasy. He had fallen backwards, hitting the back of his head. Initially he had lost consciousness. He is now alert but irritable and disorientated. There are no other known injuries. The patient has a past history of hypertension but is taking no regular medication.



Q.1


What are the principles in assessing this patient?


In the emergency department he is drowsy, eye opening to voice, localizes to pain and is orientated. His vital signs are HR 94, BP 110 systolic, RR 12, sats 98% on room air. He has oxygen applied, intravenous fluids commenced and a cervical collar already applied. A chest X-ray shows no abnormality. He complains of tenderness in the right occipital area when palpated but there is no observable laceration or bruise.



Q.2


What are the key features of his neurological examination? What is the Glasgow coma score (GCS) and why is this important?



Q.3


What are the appropriate next investigations?


You perform the most important investigation, shown in Figure 42.1A, B.


image

Figure 42.1



Q.4


What do the tests show and what is the significance of the finding?


The patient’s condition improves and he is now eye opening intermittently, obeying commands and orientated, though intermittently drowsy. He is transferred to the high dependency ward for ongoing observation and management.



Q.5


How should he be managed in the first few days?


The patient continues to improve clinically for the first 6 days and is now sitting out of bed, alert and even walking with assistance on the ward. In fact on day 6 the patient absconds from the neurosurgical unit and is discovered hours later at his home! He is brought back to the hospital. The following day, after a morning walk, he is left by his wife to have an afternoon sleep on the ward. Later that afternoon he is found on the floor by nursing staff, unresponsive with a GCS of 4 (E1, M2, V1) extending to pain with fixed and dilated pupils.



Q.6


What is the significance of the clinical signs and what should be done?



Q.7


The patient is intubated emergently and an urgent CT head scan is performed. What does Figure 42.2 show?


image

Figure 42.2


The patient is taken to the operating room and undergoes emergency frontal craniectomy, durotomy and insertion of an external ventricular drain. The intraoperative pathology is shown in Figure 42.3.


image

Figure 42.3 The intraoperative photograph shows that a bifrontal craniectomy has been performed and looking from a lateral position the dura over the frontal and temporal lobes is tight from raised pressure. Dural slits have been made to decompress the dura. Through them contused cortex can been seen. An intracranial pressure monitor will be placed prior to scalp closure.


The patient is then transferred to the intensive care unit postoperatively intubated and ventilated. Although initially fixed and unreactive, the pupils eventually become reactive and purposive movement is observed to painful stimulus.


The patient is extubated after 5 days and discharged to the ward. The patient makes a slow recovery while on the ward but eventually is transferred to a rehabilitation facility. He returns in 8 weeks to have the bone flap replaced and is discharged back to the rehabilitation facility, mobilizing freely but with significant impairment in judgement and impulse control.



Q.8


His family ask what his prognosis is. What do you tell them?

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Fall during a fishing weekend

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