Traumatic Brain InjuryCase Studies

Case Study #1

16 year old male, jumping from bridge, slipped and struck head on railing before hitting the water.

Came up above water, but appears dazed and slow to respond to questions.

His mother brings him to the local emergency department.

On your initial assessment, he is amnestic to the events surrounding his injury, oriented to person, place and time, and is complaining that “the back of my head hurts”. The rest of his exam is unremarkable.

Does this patient require a head CT?

A. YesB. No

This Head CT Shows:

1. Epidural Hematoma2. Subdural Hematoma3. Subarachnoid Hemorrhage4. Shear injury5. No acute injury

Based on his physical exam, mental status and head CT results, he should:

A. Have another CT scan in 6 hours

B. Be discharged to home with his mother

C. Be admitted to the Trauma Service for at least 24 hours

D. Spend the night in the Emergency Department

As you are preparing his discharge paperwork, he says, “GOOD! I have football practice tomorrow!” Can he play?

A. YesB. No

When can he return to football?

A. When he says he feels fineB. When his mother thinks he is well enough to playC. After further evaluation demonstrates that he is no longer suffering from post concussive symptoms.

Case Study #2

75 year old woman, tripped over dog, striking head on floor. She sustained a brief + loss of consciousness, prior to waking up with her daughter at her side.

Daughter transports her to local Emergency Department.

She is awake and alert, and complains of “the worst headache of my life”

She is evaluated by the ED staff, who call you once they see her head CT

This Head CT shows:

A. Epidural HematomaB. Subdural HemorrhageC. Subarachnoid HemorrhageD. SAH & EDHE. SDH & EDHF. No acute injury

Epidural Hematomas are often associated with

A. Cervical spine fractures

B. Parietal skull fractures

C. “the worst headache of my life”

D. Venous bleeding

Subarachnoid hemorrhages frequently

A. Require surgical evacuationB. Produce “the worse headache of my life”C. Produce significant “mass effect”D. A & CE. All of the aboveF. None of the above

She is admitted to the trauma service, hemodynamically stable and in no acute distress.Your two main goals of care in the immediate future?

A. Get her a diet and a blanket

B. Consult PT and OTC. Prevent hypoxia and

hypovolemiaD. Contact case

management and arrange for transfer to skilled nursing facility

Does she require a repeat Head CT?

A. YesB. No

Case Study #3

22 year old man s/p single vehicle MVC vs. tree. EMS finds him unresponsive (GCS 3). He is intubated without drugs, IV access is initiated and he is transported to the ED for evaluation.

Trauma evaluation notes a right forearm deformity, and scattered abrasions.

Prior to admission to the Trauma Service, he is taken through the CT scanner:

This Head CT shows:1.Epidural Hematoma2.Subdural Hematoma3.Subarachnoid

Hemorrhage4.Shear injury5.No acute injury

Your two main goals during his resuscitation are to prevent ________ and ________.

A. Pressure ulcers, contractures

B. Family arguments, disagreements

C. Hypoxia, hypovolemia

D. Pain, discomfort

He has an ICP monitor placed, with ICP’s ranging 8-10.He remains hemodynamically stable, and is cleared to

have his forearm repaired by the Orthopaedic service.

On Hospital Day #4, he is trached and PEG’d, and weaned from the ventilator by hospital day #5.

His ICP monitor is discontinued.

His family asks you, “When will he wake up?”

A. He may never wake upB. The longer he remains comatose,

the less likely it is for him to wake up

C. If he wakes up, he will likely emerge through several phases of the RLA scoring system.

D. It will take up to a year to determine his long term, “new normal”, baseline.

E. All of the aboveF. None of the above

Speech Therapy is consulted for a cognitive evaluation. They report that he is functioning at a RLA II level. You can expect him to have:

A. No responseB. Confusion with

agitationC. Generalized responsesD. Confusion without

agitationE. Appropriate responses

He progresses to a RLA III (localized response) emerging IV (confused, agitated). PT and OT come to evaluate him.You anticipate they will recommend

A. Skilled Nursing Facility

B. Inpatient Rehabilitation

C. Home with FamilyD. LTAC