No known medical illness
Alleged MVA ( mechanism of injury not known )
brought in to hospital by passerby ( Hospital Banting )
GCS upon arrival in Hospital Banting was 14/15 ( was confused )
Then pt fitted once , following which IV Valium was given - then GCS dropped to 7/15
Was intubated in Hospital Banting and sent to HTAR for CT Brain
|General||:||Upon arrival in ED|
GCS : E1VtM5
Pupil : Pinpoint ( on IV Midamorphine )
|Respiratory||:||Clear,equal air entry|
|Diagnosis||:||CT Brain findings ( Done at 11pm on 27/06/09 ) :|
Thin EDH seen at the (L) posterior fossa measuring 1.5cm in thickness x 4.5 cm ( seen over 4 slides )
+ temporal contusion seen at the base of (R) temporal fossa
- no midline shift
- Basal cistern patent
He was treated with cerebral resuscitation and ICP monitoring. A repeat CT scan was performed on 28/6/09 showed slight increased in size of EDH, however ICP maintained below 20mmHg.
EET tube was dislodged 2 days later. He was reintubated. Repeat CT scan done.
ICP noted increased trend about 26mmHg. He was subjected for posterior fossa craniotomy.