Tuesday, July 7, 2009

Traumatic Extradural Hematoma

REFERRED CASE FROM HTAR

20yrs/Malay/Gentleman
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

PHYSICAL EXAMINATION
General : Upon arrival in ED
GCS : E1VtM5
Pupil : Pinpoint ( on IV Midam
orphine )
CVS : DRNM
Respiratory : Clear,equal air entry
Abdomen : Soft
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.

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