Kap_3 - vl2ss

[ArchivalUser]

blueee:
thanks. lol I was away from the desk after giving the answer but not submiting, and when I returned I read the last sentence..thought it was stroke.

[ArchivalUser]

answer d

[ArchivalUser]

The correct answer is D. The patient is a young male involved in a motor vehicle accident with
evidence of head trauma. On initial observation, the patient appeared to be stable and his coma
score was within normal range. The major injury seemed to be his left leg fracture and possible
laceration of his femoral artery. As he was to undergo angiography of the left leg, he had an abrupt
change in his mental status. The elevated blood pressure, respiratory irregularities (Cheyne-Stokes
breathing), and the bradycardia are evidence for increased intracranial pressure (Cushing triad). The
fixation and dilation of the right pupil suggest possible uncal or brainstem herniation. The first step is
to immediately intubate the patient for airway control as the patient's brainstem is at risk. Secondarily,
intubation and hyperventilation can reduce cerebral blood flow and attenuate increasing intracranial
pressure. The next step is to reduce intracranial pressure to prevent further herniation with
administration of one bolus dose of mannitol. And lastly, a head CT is required to determine the type
of trauma, such as a hemorrhage, and to distinguish if the case is operable or not.

The change in mental status and the vital signs are indicative of increased intracranial pressure, and it
is imperative to reduce cerebral blood flow to limit the increase. Intubation and hyperventilation can
cause a limited reduction in intracranial pressure. Mannitol must be administered next, to effectively
decrease the pressure further before any other intervention to prevent additional herniation. This is the
emergency treatment that must be done before he has the CT scan. Therefore, a CT scan of the head,
intubation, mannitol administration (choice A) and intubation, CT scan of the head, mannitol
administration (choice C) are the correct interventions in the wrong order.

CT scan of the head, phenytoin bolus, thiamine (choice B) is inappropriate because intubation is
always the first step in this situation for airway control. This choice omits this step as well as mannitol
administration.

Intubation, mannitol administration, MRI of the head (choice E) is inappropriate because this choice
includes a head MRI instead of a CT scan. An MRI is a longer procedure, and for the initial evaluation
and decision for surgery a non-contrast head CT scan is sufficient.