SOLVED12

Situation: Jouri, 23 years old, had a fall on her back while riding a horse. She landed awkwardly on her back, and immediately felt a sharp pain in her upper back. Her friend, Maya, rushed to her and seeing Jouri in pain and unable to move. She dialed the emergency number to call paramedics. After 1 hour paramedics arrived and performed Jouri’s assessment. Collect cues from Paramedics: Neurogical assessment > GCS: eye opening- spontaneous, verbal-oriented although drowsy, motor-can obey commands(blinking eyes,poking tongue out), some recall of the accident. > Pupillary assessment: PERRLA (pupils equal, round, and reactive to light and accommodation). >motor function: unable to move legs or thorax. > sensation: reporting no sensation below the armpits, including thorax, abdomen and legs. Normal sensation in arm, neck, face and head. >deep tendon reflexes: normal biceps and triceps reflex. Minimal quadriceps(knee jerk) and gastrocnemius(achilles tendon) reflexes. Vital signs taken by paramedics: >Respiratory rate: 28bpm, abdominal expansion but thorax not expanding, some us of accessory muscles >SpO2: 93% started oxygen administration 15L/min via non-rebreather mask > Blood pressure: 100/72 mmHg (MAP 81mmHg) >Heart rate: 82bpm >temperature: 35.2 degrees celcius After the initial assessment, the paramedics stabilised Jouri’s spine with cervical collar and placed a long spine board to prevent further injuring during transport. They called helicopter which took 30mins to arrive. The paramedics carefully loaded her into the helicopter and transport to the Royal Hobart Hospital for further evaluation and treatment. Throughout the journey, the paramedics continuously monitored her vital signs to ensured her conditioned remained stable. They reassured Jouri and kept her informed about what was happening which helped Jouri to keep calm during this stressful event. Triage Vital signs on arrival: >RR: 26b, some use of accessory muscles. >SpO2: 97% titrated to 5L/min via Hudson mask >BP: 98/70mmHg (MAP 79mmHg) >HR: 64bpm >Temp: 36.8 degrees Celsius(tympanic) Primary survey 10minutes later: >airway: intact and unobstructed. Jouri’s voice was loud and clear >breathing: RR 28bpm, nasal flaring, absence of chest movement, oxygen required to maintain SpO2 >circulation: BP 96/64mmHg(MAP 75mmHg), HR 62bpm, peripheries warm and pink >disability: Jouri reported a loss of sensation below her chest. Reflexes-normal biceps and triceps, all other muscle stretch reflexes in the lower extremities were absent. • Sensory: perception of sensory stimuli ended bilaterally at an imaginary line drawn across her chest 2cm above the nipples, some sensation in her arms, but could not localise touch or describe texture with any consistency. • Motor: able to elevate shoulders and isometrically contract biceps and triceps in both arms, lower limbs flaccid, nil ability to move. • Deep tendon reflexes: normal biceps and triceps reflex. Absent quadriceps(knee jerk), gastrocnemius(achilles tendon) and plantar(babinski) reflexes • blood glucose: 6.2 mmol/L >exposure: nil evidence of injuries Pain assessment: >Provoking/palliating: nothing particularly provokes the pain, it is just present >Quality: stabbing and aching >Region/radiation: upper chest and medial surface of the arms >Severity: 7/10 >Timing: worsening since the accident Neurological assessment in triage: >GCS: eyes 4, verbal 5, motor 6 >Pupils: PERRLA, pupils 3mm >Limb movements: as above in “disability” notes Assessment and investigation data: Computerised tomography report: Exam information: Modality: CT Body part: Neuro Description: CT brain and c-spine Date performed: 11/11 @ 1330 Final Report: CT brain and C-spine Clinical notes: Witnessed fall from horse riding, immediately unable to stand up or reposition herself Findings: A nine-contrast CT has been acquired T2 lesion with no vascular haemorrhaging noted but some blood evident at T1-T2 with small bone fragments in the spinal canal. Mild contusion on L scapular area Impression: Hyperextension thoracic spine fracture(HTSF) at T2 spinal cord Chest X-ray: Absent lateral expansion during inhalation, normal diaphragmatic excursion, mild pulmonary oedema Actions and interventions: >spinal precautions and then immobilisation and stabilisation of spine >intravenous therapy >vasopressor therapy to maintain MAP below 85mmHg >1/24 hourly neurological assessment(GCS,Pupillary response, limb strength) for 12 hours >1/24 hourly vital signs assessment >telemetry >mechanical ventilation >analgaesia and 2/24 second hourly pain assessment > insertion of indwelling catheter urinary catheter and fluid balance monitoring >pressure risk management >thermoregulation support – maintain body temperature between 35.5 to 38.0 degrees celcius : In Jouri’s triage data, consider the cue cluster of MAP 79mmHg, Heart rate of 64bpm and peripheries warm and pink. Using the physiological and pathophysiological mechanisms and describing anatomical structures involved, explain why Jouri is presenting with MAP 79mmHg, heart rate 64bpm and peripheries warm and pink, used the data from case scenario that support the arguments.
SCIENCE
HEALTH SCIENCE
NURSING
CXA 240

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