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 Midamorphine ) | ||||||
| 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.
No comments:
Post a Comment