trauma

1. I was on shift when a 44 yr. old female BIBA due to collapsing in the shower. As patient was
on her own in bathroom, query head strike as patient wasn’t able to recall exactly what
happened but denied LOC, nausea or vomiting. Patient’s husband advised she had complained
of headache for 2/7 days and had been taking regular analgesia with no effect and had told him
her right arm and hand felt weak.
Primary assessment attended found no immediate threat to airway, breathing, or circulation. Pt
found to be hypertensive at 180/110. Patient was drowsy and confused to place and time, GCS
14/15, E3V5M6. PEARL 3mm, with internuclear opthalmoplegia to the Right eye, noticeable
facial droop, weakness, though tongue was not deviated. Pt kept trying to raise her head up
but was unable to, continued to look down frequently. Extensive Right side weakness, upper
limb motor was 3/5, lower limb 3/5, Plantar response equivocal on R) flexor on L). Pt suffered
with hypertension, and seasonal asthma on salbutamol puffers PRN, heavy smoker a pack of
40 cigarettes a day, denies drug use, and is a social drinker. Allergic to Penicillin, query
reaction. Working diagnosis of CVA L) side, CT ordered, Bloods taken, VBG attended noted
low Potassium. Due to patient been extremely hypertensive BP >200/100, tachycardic 115,
SpO2 99%RA. Pt moved to resus, commenced on Hydralazine infusion as no Labetalol
available at our rural hospital. K+ and Mg++ as bilateral IVC’s with hydralazine boluses then
esmolol infusion. Arterial line inserted into Right ulnar to monitor bp more closely as having
a art line gives you the most accurate readings. reference merle and why? IDC inserted.
FACEM had discussions with neurosurgery in our largest tertiary hospital who had reviewed
CT – not for NSx – SUGGESTED P control and stroke team management. Discussions with
our second largest tertiary hospital ICU & Medical Team consult, pt was accepted and
requested retrieval team to be paramedics familiar with infusions, All esmolol stocks in our
rural hospital exhausted on advice from NEURO TEAM to administered 10mg Amlodipine,
Swallow assessment attended by me and patient failed due to GCS declining, and noticed,
tongue was deviated to left so I made the patient Nil by mouth, informed FACEM and
suggested if we could place a NGT in to administer the Amlodipine, which was successful.
Retrieval paramedics arrived with further esomolol at same time as further esmolol arrived via
a taxi from our closet hospital. Pt recommenced on esomolo infusion, with extra prepared for
transfer. Pt was administered 8mg IV antiemetic as a prophlaxis pre transport and as patient
had been restless and more agitated, boluses of Fentanyl for comfort was administered. Pt
taken for CT Brain reported Left lentiform nucleus and external capsule haemorrhage resulting
in right sided weakness, facial droop and slurred speech.

2. ICH around left thalamus area, without ventricular extension, nor mid line shift. Pt continued
to be hypertensive

3. As a shift worker we work on a rotating shift throughout our 2 week roster I am a full time
worker and on this particular crazy busy evening I regret that I came in cover sick leave.
I was allocated Resus/Fast Trak and Isolation, as the patient I had been caring in Resus had
been transferred off to another hospital. I finished off assisting the Nurse Practitioner, relived
Triage and assisted where I was needed.
I walked into the acute side of the department and noticed a couple of young girls and boys,
sitting in one of the Sit Chairs, Introduced myself and asked who the patient was and what
had brought her into ED today.
The 18 year old lady reported she has been having left sided uncontrollable headaches, since
this morning and even though with regular analgesia wasn't effective. The patient’s friends all
laughed informing me it was because the patient had just had celebrated her 18th birthday
party the night before and had been very intoxicated and was dropped by a friend accidently
landing on the Left side of her head drop of approx. 3 meters high. I was thinking MOI was
significant and was thinking at that stage she may have a brain injury or fractures.
Patient was triaged as Category 4. I checked if the primary nurse was happy for me to start
the nursing assessment as it was crazy. As I was taking the patients observations, one of her
friends informed me that the patient was starting to get vague and didn’t appear to be
behaving normally. The patient blamed it on the lack of sleep and was adamant she wasn’t
dropped on her head she appeared puzzled and informed me that she couldn’t recall the night
before or the incident that she was dropped her on her head.
Pt passed her primary & secondary assessments with flying colours, though the headache was
severe. I commenced neuro observations GCS 15/15 =Upper and lower limb strength,
mobilising well. Cranial nerves were intact NAD.
At that moment I saw a senior CMO who said she clicked on the patient and had been
observations the patient visually and was here to review and discharge patient and requested
that I present the Head Injury Information Sheet to the patient as ready to be discharged as
her observations were normotensive.
I felt that I need to advocate for my patient and give the CMO more information so politely
asked if I could have a word, at that stage I informed CMO that I was a little uncomfortable
in sending the patient home just yet informing her of what the friends had informed me which

4. the patient had forgotten but was in denial about a friend lifting her up accidentally dropping
her from 3 meters high, her friends had informed me.
I informed the CMO that the patient didn’t have any neurological deficits patient was alert
orientated, PEARL, 4mm, no change to diameter of pupil, no photophobia, no leakage of
fluid from ears, or nose but the patient was unsure and continued to say her headache was
10/10 the CMO stated “well we better do a CT Brain.
The patient was examined by the CMO and a CT Brain was ordered. Urine dipstick negative,
UHcg –negative. Pt had a superficial/hematoma on the parietal side of head. So we gave her
a narcotic analgesia to assist with her pain and I then took her in a wheelchair to imaging for
her CT.
CT results Linear skull fracture on the squamous suture (are fibrous joints between the bones
of the skull) between the temporal and parietal bones of the skull, They are usually fairly
straight with no bone displacement but because it was close to the suture and due to the
swelling on L) side of the patients head. Pt was transferred to our large teriatory hospital for
review by the Neurologist. Due to the closeness of the fracture to the squamous suture as it
lies outside of the brain, artery may have potentially ruptured, causing the patient to sustain
an extradural hematoma, as blood will accumulate between the brain and the dura mater.
You’re at risk of getting an extradural hematoma if you get a structure through the pterion