Case Presentation
Agron Ashtbi, an 18-year-old Albanian Olympic gymnast, is practicing his routine on the parallel bars for the upcoming Olympics. The routine ends with a complicated rotational dismount, during which Agron’s right hand slips and the right side of his neck near the back of his head collides solidly with the bar. He falls to the mat beneath, attempts to stand, but immediately begins to slouch, and subsequently collapses. The team’s physio rushes to assess Agron and, realising he has become unconscious, places Agron in the recovery position and immediately calls emergency services. They arrive within minutes.
Q1a. Outline the approach paramedics should take in both assessing and managing Agron on their arrival at the gymnasium.
DRSABCDs stabilise neck with brace gather history from people around acertain identity GCS and try NIHSS
Q1b. Agron has sustained trauma to the posterior-lateral part of the neck on the right side. With reference to the posterior arterial supply to the brain, injury to which vessel could be responsible for his rapid loss of consciousness following external blunt force trauma?
PCA
Clinical Update
Agron is rushed to the Emergency Department [ED] of a close-by tertiary care hospital. On arrival in the ED he has a GCS of 5 [E2, V1, M2]. Vital signs Temp 37.1 BP 154/60 Pulse 42/reg Resps 10/min and irregular O2 sats 86% on room air Blood glucose normal ECG shows sinus bradycardia
Agron is exhibiting Cushing’s Triad [Bradycardia, widening pulse pressure and irregular breathing], something seen in the late stages of acute traumatic brain injury. It is a sign of a marked rise in intracranial pressure. The immediate severity of his traumatic brain injury has meant that many of the earlier signs and symptoms of raised intracranial pressure have not been demonstrated.
Q1c. List two [2] earlier signs and two [2] earlier symptoms of raised intracranial pressure in an adult, which may or may not include meningeal irritation.
kernigs sign papilloedema
photophobia headache
Q1d. According to the Monro-Kellie doctrine, what pathological changes could be seen in the brain if the intracranial pressure continued to rise unchecked?
we should see that as pressure increases, blood perfusion wil decrease and the brain will experience a pressure gradient which may cause herniation
Question 2 [10 minutes]
Q2a. Agron undergoes urgent CT. Describe [in general terms] the pattern of hyperdensity seen in the CT below. (Image provided in original PDF showing hyperdense material in basal cisterns)
the pattern seems to be hyperdensity in the basal CSF cisterns, consistent with subarachnoid bleeding
Q2b. What does this pattern reveal as the basis for Agron’s rapid neurological decline following blunt force trauma to the upper part of the back of his neck?
severe subarachnoid bleed
Q2c. Explain why fresh blood appears hyperdense on CT and what changes in density occur with time following the bleed.
fresh blood has high concentrations of haemoglobin, and this appears hyperdense, especially as it clots, as the RBCs contract together. eventually the hyperdense protein gets phagocytosed and broken down by macrophages and eventually is hypodense
Clinical Update
Agron’s family took five hours to get to the hospital. Although their son underwent surgery, his GCS declined further over the next 24 hours, and he never regained consciousness. The discussion turned towards sustaining his life, which now relied on him being mechanically ventilated.
Q3a. With reference to the ‘RUB’ [Risk for Unacceptable Badness], outline two [2] important considerations that doctors might use to inform their decision-making regarding next steps for Agron.
if he were saved then what is the quality of life which will be sustained. if we are to keep him in the state where he is now,
Q3b. Could Agron’s parents make these sorts of decisions on his behalf? [Why, why not?]
they are important is deciding what he would want, but cannot make direct decisions for agron
Clinical Update
Agron was taken off the ventilator and was pronounced dead within thirty minutes. His family and friends grieved deeply, and he was buried in a plot set aside for the Ashtbi family. Beside Agron was his grandmother, Sophie, who had suffered a Stroke and died two years previously. Sophie had suffered from atrial fibrillation.
Q3c. Name and supply the mechanism of action of one [1] medication that could be used to help minimise risk for Stroke where a patient has atrial fibrillation. [NB: You need only supply details for one medication, even though more than one medication would be required]
clopidogrel, as it inhibit the D2 receptor leading to reduced platelet aggragation and clotting