The Case

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CASE HISTORY

Jake Carwin, a 24 year old man, was riding his motorbike when a car turned in front of him; he hit the car and was thrown through the air, landing on his chest, then striking his head on a curb with significant force.

His helmet was severely damaged.

Bystanders called an ambulance.

Paramedics arrived within 6 minutes.

He was found to be tachypnoeic (RR30), hypoxic (initial oxygen saturations 89%), hypotensive (BP 89/50 mmHg) and tachycardic (HR 115).

He would not open his eyes to a painful stimulus, was extending his arms to painful stimuli and was not making any verbal response to pain.

His pupils are currently both 4 mm and reactive to light.

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What’s his GCS?



Right now it is:

E1
V1
M2

(See the GCS lesson for some nuances on doing this)

It should be noted that this is an un-resuscitated GCS.

He’s hypoxic and hypotensive at this stage which will confound the neurological assessment.

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What are the initial priorities?



Cervical spine immobilisation

Provide oxygen for sats > 90%

Protect airway

Resuscitate to achieve SBP > 110 mmHg

Quick transport to the closest appropriate trauma center

If there’s clinical suspicion of a haemo/pneumothorax, a finger thoracostomy is warranted

The extensor posturing suggests EICP so consider:

  • Mild hyperventilation aiming ETCO2 30-35 mmHg
  • Bolus of hyperosmolar agent e.g. 3 ml/kg 3% hypertonic saline

*Note this is a broad overview only*

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