Integrated Case Test: April 6, 2022
Course: MICN 301 Time allowed: 45 minutes total
Case Presentation
Jess Hanron is a 26-year-old hairdresser who developed epilepsy shortly after her 21st birthday. Jess’ epilepsy has been well controlled with Dilantin [Phenytoin] but she and her partner Tim are wanting to start a family and Jess has heard that phenytoin can cause damage to the developing foetus. She decides she will try to wean herself off the phenytoin, so instead of taking 300mg every day, she starts taking 300mg every other day and sometimes she misses out the odd dose just because she forgets. It has now been four weeks and Jess is feeling quite well and hasn’t had any seizures.
Jess didn’t consult with the GP about her plans because her GP expressed amusement during Jess’ last visit when Jess said she used natural remedies for her intermittent aches and pains. Feeling a little humiliated, Jess stopped short of telling her GP that she regularly took Vitamin C and Oil of Wintergreen [Methyl Salicylate] and she never went back.
Today Jess is having lunch outside with her friend Priya at a local café. Priya makes a humorous comment about a woman at the next table and Jess leans back in her chair and throws her head back, laughing. Priya is laughing too, but then realises Jess is no longer laughing, but making a weird sound and falling backwards towards the ground. Priya tries to grab Jess, but cannot reach her and Jess’ head hits the tiled deck with a sickening thud. Priya and other diners rush to Jess’ aid. Immediately on hitting the ground, Jess, who appears unconscious, begins to have a generalized tonic-clonic seizure. Jess’ limbs stiffen then begin to jerk violently. She froths at the mouth and has a bluish tinge to her lips. There is blood on the tiles making efforts to help Jess slippery and awkward. The seizure lasts a good few minutes before ceasing.
Question 1 (25 minutes)
Q1a. Outline the approach you [as a third year medical student] would take to managing Jess during and immediately after the seizure.
DRSABCDs there is danger from slippery surfaces and blood so send someone in the cafe to get towels, then check for response send for help, then preserve airways check for breathing, try to stem bleeding with first aid kit. cpr if no heartbeat and then Defib.
additionally stabilise neck in the case of neck fracture
attempt to cushion head during seizure
Q1b. Outline and provide a rationale for the approach paramedics would take to assessing Jess at the café following her seizure and prior to transfer to the Emergency Department.
stabilise for hospital, neck brace and ensure vitals are maintained. do a gcs and comfort her
Q1c. Explain why prolonged seizure activity [greater than 5 minutes] is to be avoided and name one clinical sign Jess exhibited that demonstrated the inherent danger.
asphyxiation from lack of breathing as well as aspiration of saliva and spit
Clinical Update
Jess is transferred quickly to the local tertiary care hospital and on arrival remains drowsy and incoherent, but does open her eyes and localizes to pain. Her GCS is repeated and is 9 [E2, V2, M5]. Her head wound is inspected and requires suturing, but there is no external evidence of a depressed skull fracture.
Q1d. Why may a GCS in this instance not be completely adequate in assessing Jess’ level of consciousness?
shes likely post ectal which can have its own effects separate from head trauma or lack of oxygen
Question 2 (10 minutes)
ED staff need to assess the extent of her head trauma, so Jess undergoes CT of the head. The CT reveals an acute subdural haemorrhage present in the occipital lobe.
Q2a. Taking into account the location and the nature of the injury to Jess’ head, describe in detail what you might expect to see on the CT head scan.
a crescent shaped hyper dense mass wrapping around the brain
Q2b. If Jess were to survive a severe acute subdural haemorrhage in the occipital lobe, what are two [2] types of neurological deficit she may be left with?
vision loss and beign unable to name objects or spatial reasoning deficits
Q2c. Jess’ fall would have been approximately from a distance of one metre onto tiles. What one [1] factor other than distance to fall and falling onto a hard surface, could have uniquely predisposed Jess to intracranial haemorrhage as a consequence of trauma?
methyl salicylate (oil of wintergreen) functionally similar to aspirin, which possesses antiplatelet activity.
Clinical Update
Jess experienced further bleeding and deteriorated over the following 24 hours. Despite decompressive surgery and aggressive rehabilitative treatment, a year later at 27, Jess is left with neurologic deficits. She is visually compromised, constantly fatigued and still experiences a lot of headaches. Although she has retained mobility, Jess feels she can never again be the person she once was. She feels her life is ruined and her hopes of ever having a family have faded. Tim continues to support Jess, but their relationship is under a great deal of strain.
Neurosurgery continue to monitor Jess and deem her progress to be satisfactory considering the severity of her head trauma. However, Jess does not feel similarly. She has a new GP whom she gets on very well with and who has a real interest in helping patients with brain injury recover to the fullest of their potential.
Question 3 (10 minutes)
Q3a. Outline two [2] pathways for assistance that Jess’ new GP could suggest to Jess and explain how they could assist. This could mean referral to other health professionals, organisations or individuals with the appropriate expertise.
supportive physical therapy. this can help jess deal with her physical symptoms and increase body energy via physical training
can suggest disability advocatcy networks, to help her find peers, and to advocate for her when she is in tough positions
Answered
Question 1
Q1a. Approach to managing Jess during and after the seizure:
- During the seizure: Ensure scene safety (DRSABCD). Do not restrain her or put anything in her mouth. Protect her head from further injury (e.g., place something soft underneath). Time the duration of the seizure.
- Immediately after: Once the jerking stops, place her in the lateral recovery position to maintain airway patency and allow frothy secretions/blood to drain. Monitor her airway, breathing, and circulation until paramedics arrive.
Q1b. Paramedic approach and rationale:
- C-Spine Immobilization: Rationale: She had a backward fall onto a hard surface; cervical spine injury must be assumed and protected.
- Airway/Breathing/Oxygenation: Rationale: She exhibited a bluish tinge (cyanosis), indicating hypoxia. They will secure the airway, administer high-flow oxygen, and suction if necessary.
- Neurological Assessment (GCS/Pupils): Rationale: To establish a baseline level of consciousness, assess for signs of raised intracranial pressure from the head strike, and monitor her post-ictal recovery.
- Point-of-care Blood Glucose: Rationale: Hypoglycemia can trigger seizures and must be ruled out or treated immediately.
Q1c. Prolonged seizure activity and inherent danger:
- Why to avoid: Prolonged seizures (Status Epilepticus) lead to sustained failure of ventilation, resulting in profound systemic hypoxia, hypercapnia, and metabolic acidosis. This rapidly causes irreversible anoxic brain injury and neuronal death due to excitotoxicity.
- Clinical sign: The bluish tinge to her lips (central cyanosis), indicating severe hypoxia.
Q1d. Inadequacy of GCS in this instance:
- Jess has just experienced a generalized tonic-clonic seizure. She is in the post-ictal phase, characterized by transient drowsiness, confusion, and depressed consciousness. Therefore, her low GCS of 9 may be artificially depressed by the seizure itself, rather than purely reflecting the structural traumatic brain injury.
Question 2
Q2a. Expected CT head scan findings:
- A hyperdense (bright/white) crescent-shaped collection of blood located peripherally over the occipital lobe.
- The collection will cross cranial suture lines but will be bound by dural reflections (e.g., it will not cross the tentorium or falx cerebri).
- Potential signs of mass effect, including effacement of local sulci, compression of the posterior horn of the lateral ventricle, or midline shift.
- Possible overlying scalp hematoma/swelling at the site of the laceration.
Q2b. Neurological deficits from an occipital lobe injury:
- Contralateral homonymous hemianopia (loss of half the visual field in both eyes).
- Visual processing deficits, such as cortical blindness (if bilateral) or visual agnosia (inability to recognize objects).
Q2c. Unique predisposing factor for intracranial hemorrhage:
- Jess is taking Oil of Wintergreen (Methyl Salicylate). Salicylates act as potent antiplatelet agents (similar to aspirin). This drug-induced coagulopathy uniquely predisposed her to significant bleeding from the trauma.
Question 3
Q3a. Pathways for assistance:
- Referral to a Clinical Psychologist or Counsellor: Jess is expressing profound grief over her lost identity, dashed hopes for a family, and relationship strain. A psychologist can provide cognitive behavioral therapy and support to help her navigate adjustment disorder, depression, and relationship counseling with Tim.
- Referral to a specialized Brain Injury support organization (e.g., Brain Injury Association NZ) or Occupational Therapist: These organizations provide community support, vocational rehabilitation, and strategies for managing chronic fatigue and sensory deficits, helping Jess regain independence and a sense of purpose.
in review
- remember neck brace
- information from priy
- remember pupils. (perla)
- All CT observations
- hypoglycaemia
- post ictal phase
- occipital lobe injury
- interprofessional assistance