Problem
Enzo Bihari is a 19?yo?full time university nursing student. He keeps fit by riding mountain bikes, running and plays with the?uni?hockey team. He lives in a share house?while on campus and goes home for holidays. He also works part-time as a bartender.
He went to the beach with some friends on a hot Saturday and hit his head on a sand bank when diving into the water. His friends saw him dive in and realised very quickly that although he was floating face down in the water, he wasn't fooling around and actually was unable to turn over. His friends and lifeguards turned him, supporting his neck, and kept him warm until the paramedics arrived.
Vital signs:
RR: 32 bpm (shallow)
SpO2: 89%?on O2 15L/min via non re-breather mask
BP: 94/55?mmHg?? (MAP 68 mmHg)
HR: 64 bpm
T: 37.9oC (tympanic)
Neurological assessment:
GCS: eyes - 4; Verbal - 5; Motor - 6
Pupils: pupils equal (4 mm), round, and reactive to light and accommodation (PERRLA)
Limb movements: as above in "Disability" notes
Computerised Tomography report
Exam Information
Modality: CT
Body Part: NEURO
Description: CT Brain and C-Spine
Performed Date: 25/3/Year Time: 1330
Final Report
CT BRAIN AND C-SPINE
CLINICAL NOTES:
Witnessed dive into shallow water at beach. Immediately unable to reposition himself from being face-down in the water.
Findings:
A non- contrast CT has been acquired.
C6 lesion with no vascular haemorrhages noted but some blood?evident at C5 - 6 with bone fragments in the spinal canal.?
Mild frontal lobe contusion
IMPRESSION:
Unstable C6 compression fracture
X-ray
Chest - decreased lung expansion upon inhalation; mild pulmonary oedema
Arterial blood gases
1) pH?-?7.27 (ref range: 7.35 - 7.45)
2) PaO2?-?60 mmHg (ref range:?75 - 100 mmHg)
3) PaCO2?-?52 mmHg?(ref range: 35?- 45?mmHg)
4) HCO3- -?25.2 mmol/L (ref range:?22 - 26 mmol/L)
5) SaO2?-?88%
Take Action
"1/24 (hourly) neurological assessment for 12 hours" has been requested for Enzo, despite his GCS and pupillary response data being satisfactory.
Provide a rationale for this intervention by:
1) considering Enzo's accident at the beach and CT findings, and identifying a risk problem other than his spinal cord injury
2) referring to relevant anatomical structures and discussing the pathophysiological mechanisms that may cause changes to Enzo's neurological assessment; Glasgow Coma Scale, Pupils, and
3) identifying guidelines or clinical pathways that support this intervention.