Clinical Vignette Case Study

Mr James Walker is a 64 year old male, widower who lives in Brompton. He has one adult child, who lives an hour away by train. Mr Walker was found around midday by his neighbour, after falling from the top of a 3.6 metre ladder whilst cleaning the gutters. The neighbour, who witnessed the incident, informed the paramedics that Mr Walker was conscious and had reported that he had felt dizzy, so had tried to come down the ladder, but missed a rung. As he fell, Mr Walker tried to twist so he that would not land on his back. Instead he landed on his left side with his left arm underneath his body and hit his left temple area very hard on a rock in the garden bed.

Mr Walker has a previous medical history of osteoarthritis, secondary to Pagets disease and he has a significant bilateral hearing impediment, but frequently does not wear his hearing aides. His current  medication regime is; Fosamax (Alendronate) 70 mg tablet once weekly and Meloxicam Capsule 10 mg once a day.

Mr Walker arrived in the emergency department (ED) by ambulance at 1230 hours. Left upper arm out of alignment, swollen, vacuum immobiliser insitu and elevated on a pillow. He has abrasions to his face, both hands and abdomen; having fallen onto the gardening and flowers below. The lacerations to his hands are soiled with dirt and debris from the gutters and gardening this morning but appear superficial. He complains of pain in his left upper quadrant of his abdomen. Paramedics handed over that he was initially drowsy and disorientated, and opened his eyes to voice. Currently his neurological observations have improved. His GCS is currently 15. Spinal precautions remain insitu.

ED Summary

Observations on admission to ED (presented in no particular order)

Temp 36.5C, Heart rate 94 and regular, respiratory rate 24, BP 86/60 and administered 500mL N/ Saline, then 250mL Albumex-4 followed by 100mL/hr/N/Saline. Sp02 initially 96% on 10 L via non rebreather mask and then deteriorated to 87%, haemoptysis, rapid shallow breathing (32 bpm) and asymmetrical chest movement. On auscultation diminished breath sounds on left side. Chest X-ray showed left-sided pneumothorax with blunted costaphrenic angle indicating blood. No evidence of rib fractures – Diagnosed with left haemopneumothorax. Chest tube inserted at 1315 hours attached to Atrium Ocean drain – Suction to be titrated so that the fluid in suction chamber is gently bubbling. Obs 15minutely (HR, Sp02, BP, RR, Respiratory Effort and temperature plus patency of UWSD) for 1hr post insertion then hrly for 4 hrs.  ECG (Sinus rhythm).

Reviewed by Surgical team

 Investigations:  FBE, EUC, COAGs, Cultures, BAL; LFT; G&XM, Cardiac enzymes.

Trauma Radiology Series/ FAST/ CT:

C-Spine: head and spine – Spine cleared; Small left-sided subdural haematoma;

X-ray Chest (post chest tube insertion),  abdomen, pelvis;

Limbs – left colles fracture (realigned and Plaster of Paris insitu);

Surgical registrar Notes: 

Previous history noted.  Plan: Strict monitoring of GCS and vital signs, nursing management of chest tube. IVT @ 100 mls/hr, IDC insertion and strict fluid balance. Transfer to high acuity ward, POP care, analgesia as charted. To remain NBM until gastro team review abdo X-Ray and check bowel sounds. Keep Spo2 above 96% 2-6L 02 via N/S or HM. Will review following gastro team recommendations.

 Medications ordered:

High acuity ward charts and observations as follows

Fluid Balance Chart

Nursing Note 2000hrs:

Observations and care provided as charted. IVT continues at 100mls/hr, IDC insitu draining around 50mL straw coloured urine. GCS 14/15. At times appears to be a little inappropriate to staff in what he says, appears jovial. L) arm elevated on pillow – PoP – NAD, observations satisfactory and minimal pain to this arm. Complaining of headache, abdo pain and pain to multiple lacerations to hands. Administered morphine and IV paracetamol. All wounds cleaned with a medisponge, primapore insitu. Remains NBM, bowel sounds noted. Albert Hendon RN

Nursing note 2225hrs:

MET call 2200hrs: GCS decreased to 12 in particular became confused to location and person, became erratic. Increased systolic BP and widened pulse pressures. Increasingly agitated then drowsy, inappropriate words and localising to pain, difficult to rouse and then GCS 10/15. Pupils size 5 and right eye slow to react. Chest tube swinging and bubbling – minimal drainage last 2 hours. MET team called and requested neuro team to urgently review patient. Possible emergency craniotomy. Graham Noah RN  

CT information inserted for nurses interest

Patient taken to theatre for emergency craniotomy, then transferred to ICU for ICP monitoring and management.

Observations and facts on readmission to high acuity ward (in no particular order of importance