Management of an elderly patient with traumatic brain injury: A case study.

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Running head: Case Study

Management of an elderly patient with traumatic brain injury:

A case study

By Rima Kaddoura

American University of Beirut

“No head injury is so serious that it should be despaired of nor so trivial that it can be ignored.”(The Hippocratic aphorism).

The ancient Greek physician, Hippocrates, first discussed cerebrovascular injuries 2400 years ago. He described them as the onset of sudden paralysis.800 years later; this sudden onset of paralysis was termed apoplexy. During this time, the Swiss pathologist Johann Jakob Wepfer discovered that apoplexy (i.e. cerebrovascular injury) was caused by a disturbance in the blood supply to the brain.

Traumatic brain injury causes more than 80,000 emergency department visit in the elderly population (aged 65 years or older) each year (Gangavati et al., 2009). While motor vehicle accidents are the leading cause of traumatic brain injury (TBI) in the younger population (Susman et al., 2002), studies have concluded to other findings for the older population. More than 50% of TBI in the elderly are due to fall-related injuries, while this population constitutes 20% of all TBIs (Yap, & Chua, 2008).

These numbers are especially important when considering the fact that the population aged 65 years or older is constantly growing (Susman et al., 2002). With this change in the population’s demographics, the number of fall-related TBIs is expected to increase. In addition, this population has several risk factors that predispose them to TBI such as: muscle weakness, impaired balance (Yap, & Chua, 2008), anticoagulant use (Gangavati et al., 2009), comorbid conditions, and age related physiological changes. In fact, with older age, the dura’s adherence to the skull increases, the vessels become more brittle, and cerebral atrophy occurs (Thompson, McCormick, & Kagan, 2006).Thus, it is becoming increasingly important to acquire knowledge about this type of trauma and its respective management. The application of preventive measures and teaching this category of the population is also crucial, when taking into account that falls is one of the most preventable causes of TBI (Thompson, McCormick, & Kagan, 2006) (other causes include: MVAs, assaults…etc).

After presenting the case of a patient who was admitted to the American University of Beirut-Medical center with a diagnosis of intracranial hemorrhage, the pathophysiological process of his injury will be explained, along with the appropriate medical and nursing management, in addition to special considerations and issues.

Case presentation

 H.S is a 79 year old male known to have hypertension, diabetes mellitus type II, and prostate cancer since 13 years. His previous surgeries include a cardiac catheterization 20 years ago. He takes Aspirin, Glucophage, Amlor, and Duactin. On 18/11/2010, patient H. was going up the stairs in his building when he fell and hit his head. He lost consciousness for a time that was not identified since no witness was immediately present at the scene.

In the Emergency room 

One hour later, at 8:45 pm, he was brought to the emergency department. Upon arrival, the patient was conscious and oriented. He was anxious and agitated, and he reported a pressure pain over his head with an intensity of 9/10 for duration of 10 min. He also vomited upon arrival and after complaining of a stiff neck, a neck collar was applied. His vital signs were as follows: temperature= 36.8⁰C, heart rate= 100 beats/ min, blood pressure= 148/75 mm Hg, respiratory rate= 20 breaths/min. In addition, his blood glucose level was 197 mg/dL. An intravenous line was initiated, blood tests were taken, and a Computed Tomography (CT) of the brain was done. 5 mg of Dormicon were given IV push, and 70 mg of Mannitol were given IV Drip. The CT revealed large right temporal contusion, parietal contusion, large right subdural hematoma and midline shift.

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Afterwards, the patient desaturated and he became hemiparetic on the left side. Intubation was immediately done, a nasogastric tube was inserted, and the patient was rushed to the operating room (OR).

In the Operating room

 The patient underwent a craniectomy and urgent evacuation of subdural hematoma. Surgery however was complicated by severe bleeding and hypoperfusion. He received fluids and 2 units of platelets were transfused, in addition to 2 packs of red blood cells. After the operation was completed, the patient was transferred to the intensive care unit (ICU).

In the Intensive Care Unit

The patient was semi-comatose, he ...

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