Joel Hart, age 28, is admitted from the emergency department (ED) to your orthopedic unit with a fractured right humerus suffered in a motorcycle accident. He wasn’t wearing a helmet, and a computed tomography (CT) scan revealed a small right subdural hematoma.
History and assessment hints
Mr. Hart’s blood pressure (BP) is 146/82 mm Hg; pulse, 117 beats/minute; respiratory rate, 24 breaths/minute; and oxygen saturation, 95% on room air.
He is alert and oriented to person, place, and time, and he follows commands. Both pupils are 2 mm and react briskly to light. Thus, his Glasgow Coma Scale score totals 15 by adding 5 (is oriented) + 6 (follows commands) + 4 (opens eyes spontaneously).
An hour after admission, Mr. Hart’s Glasgow Coma Scale score drops to 12: He is sleepy but opens his eyes when asked to. His right pupil is 3 mm and sluggishly reactive; his left pupil is unchanged. When asked where he is, he says, “I’m not sure.” He no longer follows commands.
His BP is 150/86 mm Hg, and his heart rate is 108 beats/minute. His respirations are deep; the rate is 30 breaths/minute.
Call for help
You recognize that his decreased consciousness, elevated BP, and decreased pulse rate may indicate increasing intracranial pressure (ICP) from an expansion of the subdural hematoma. You activate the rapid response team (RRT) and ask the charge nurse to page the admitting physician.
On the scene
When Kim, the RRT nurse, arrives, she performs a neurologic assessment. The right pupil is now 4 mm and doesn’t react to light. Shaking the patient and shouting elicit no response. When Kim pinches the skin above Mr. Hart’s right axilla, his eyelids flutter, and he stiffly extends all four limbs. His BP is 182/68 mm Hg; his pulse rate, 59 beats/minute; and his respiratory rate, 32 breaths/minute.
Kim recognizes that Cushing’s response (elevated systolic BP, bradycardia, and rapid deep respirations) plus a nonresponsive pupil indicate increased ICP. She calls the ED physician to the bedside, and he orders 50 g of mannitol I.V. over 20 minutes and a urinary catheter. Kim hangs a 250-mL bag of 20% mannitol containing
20 g/100 mL and uses a filtered line. The physician orders a stat CT scan of the head without contrast and pages the neurosurgeon on call. Then, Kim and the ED physician insert an oral endotracheal (ET) tube to maintain a patent airway and control ventilation.
The CT scan reveals a large subdural hematoma, and during emergency surgery, the neurosurgeon removes it. After 48 hours in the intensive care unit, Mr. Hart has his ET tube removed. He is confused and slightly agitated but occasionally follows commands.
After surgery for his fractured humerus, he returns to your unit for 3 days. Then, he’s discharged to a rehabilitation facility to recover from traumatic brain injury.
Education and follow-up
The earliest sign of increasing ICP is a decreased level of consciousness, which can progress rapidly. Increasing pressure from the expanding hematoma pushes on the third cranial (oculomotor) nerve, causing the pupil to grow and stop responding to light—a finding called a fixed, dilated pupil. The mannitol causes osmotic diuresis that pulls excess fluid from brain tissue, decreasing intracranial pressure.
Teach families of brain injured patients such as Mr. Hart that recovery is slow and requires physical, occupational, and speech therapies. Explain that short- and long-term memory and concentration may be impaired and provide the name of a local social support group that can help the patient and the family.
Visit www.AmericanNurseToday.com/journal for a list of selected references.
Laura H. McIlvoy is an Assistant Professor in the Department of Nursing at Indiana University Southeast in New Albany, Indiana.