Assemble a collaborative interdisciplinary network, and refer and consult appropriately while maintaining primary responsibility for comprehensive patient care.
PO A. Initiate referral to other health care professionals while maintaining primary responsibility for patient care.
PO C. Utilize consultation recommendations for decision-making while main- taining primary responsibility for care.
PO D. Evaluate outcomes of interventions.
PO E. Provide ongoing patient follow-up, and monitor outcomes of collabora- tive network interventions.
ENCOUNTER CONTEXT
Encounter One (initial evaluation)
DNP role: I am the pediatric nurse practitioner and DNP resident seeing this patient for an initial ED evaluation.
Site: Urban academic medical center.
Setting: Pediatric Level 1 trauma center.
Reason for encounter: Child brought to ED by parents.
Informants: Parents and 12-year-old patient, who appear to be reliable historians.
Chief complaint: Headache and vomiting.
History of Present Illness
A 12-year-old male reports two days ago that he went to the park, four blocks from his home, to look for friends, but they were not in the park. He states that “nobody” was there; he heard “a fi re cracker” and then “something sliced
through my hair.” He states that he did not know what it was, but he thought a rock hit him. The patient states that he touched his scalp, and there was a little blood in the area above his right ear. He ran home, went to his room, and slept for approximately one hour. He did not tell anyone he was hit by a
“rock” in the park. He awoke from his nap feeling fi ne. He ate lunch and had no problems the rest of the day.
The following day, the patient awoke feeling sick: “my body was hot and I was sweating.” His mother cooked rice and water, but he “threw it up.”
He reports he vomited fi ve or six more times that day. Toward the end of the day he felt “dizziness,” which he describes as feeling “like my head was spinning.”
The next morning, he awoke with “dizziness” and right-sided headache,
“like something’s in my head.” When asked what was in his head, he replies,
“something like a rock.” He vomited many times through the day. The vomit- ing and the headache got worse throughout the day. His head “felt like it was moving back and forth.” If he stood up straight, he would fall to one side. His nausea improved throughout the day, and in the evening he told his mother that he had been hit by a rock in the park two days ago.
Past Health History
The patient fractured his left proximal humerus at age six after falling off a deck. This was treated with a sling and swathe. There have been no prior seri- ous illnesses, hospitalizations, or surgeries. Birth history includes full-term, normal vertex presentation vaginal delivery without maternal or neonatal complications.
Current medications: None.
Allergies: No known drug, food, or environmental allergy.
Immunizations: Up-to-date.
Social History
Patient lives with his parents and his older brother. His parents are from Laos and Thailand. They reside in the second-story apartment house near the medical center. Both parents work during the day, and sometimes the father works in the evening as a delivery truck driver. The patient states he will begin seventh grade this fall, and his grades range between B’s and C’s.
After-school time is mostly spent outdoors in the nearby park.
Cultural: The patient’s parents speak only Hmong.
Traditionally, the Hmong believe that illnesses could have natural causes (e.g., spoiled food, exposure to the elements, fall, accident); these are treated with herbs, massage, cupping, or other nonspiritual methods (Helsel, Mochel, &
Bauer, 2005).
Oxford Centre for Evidence-Based Medicine (CEBM), level 3.
Chapter 9 Adolescent Male With Traumatic Brain Injury
103
Family History
There may be a maternal history of chronic headaches. It is diffi cult to elicit a defi nitive history of actual headaches, possibly because of the Hmong belief that illnesses could also have supernatural causes.
. . . (e.g., lost souls, offended spirits, malevolent spirits); these tended to be more serious illnesses (Helsel, Mochel, & Bauer, 2005).
CEBM, level 3.
Review of Systems
Constitutional: The patient is an awake and alert male. The patient has had mild weight loss since his recent episodes of continued vomiting. The patient denies fever, but feels “sick all over” with the sensation that his head is mov- ing “back and forth.”
Head: States that he has been hit by a rock to the right side of his head two days prior and now has a cut above his right ear.
Eyes: Denies eye pain or visual disturbance.
Ears: Denies discharge or hearing loss, but does describe “dizziness” when attempting to ambulate.
Nose: Denies nasal discharge or congestion.
Neck: Denies lumps, bumps, or stiffness.
Throat: Denies diffi culty swallowing or sore throat.
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath or wheezing.
Gastrointestinal: Denies constipation or diarrhea but has had multiple epi- sodes of vomiting.
Genitourinary: Denies dysuria or hematuria.
Neurological: Complains about right-sided headache above his right ear. No complaints of lethargy or decrease in activity.
Musculoskeletal: Patient denies joint or muscle aches. Has not noticed any new lumps, bumps, or lesions.
Critical Appraisal
I requested the assistance of an interpreter to provide and incorporate culturally competent care and advocacy. As I assess this patient and his family, I am cogni- zant of their cultural beliefs (Competency 7, PO A).(Competency 7, PO A).
Skin: No new rashes or bites noted.
Hematological: No history of easy bruising.
Immunological: Immunizations are up-to-date.
Psychological: Denies feeling unsafe at home or at school. Has no thought of harming self or others.
Physical Examination
General: Alert and oriented without distress.
Vital Signs: Heart rate 100, respiratory rate 22, blood pressure 115/70, temp 100.5ºF, SaO2 98% room air. Weight 36 kg.
Neurological: His Glasgow Coma Scale is 15.
HEENT: His pupils are equally round and reactive to light. Extraocular move- ments are intact. Visual fi elds are intact to confrontation. Fundoscopic exam reveals no evidence of papilledema. His face is symmetrical. His tongue and uvula are midline. His jaw is symmetrical. His motor and sensory exam on his face is intact. Examination of his head reveals a soft-tissue swelling above the right pinna that is very tender to palpation. There is also a crusted formation over the patient’s right ear, embedded within his hair.
Respiratory: Breath sounds are clear and equal bilaterally without fremitus.
Heart: Heart rate is regular sinus rhythm, without rubs, clicks, or murmurs.
Gastrointestinal: Abdomen is soft, nontender, without masses and hyperac- tive bowel sounds.
Genitourinary: Circumcised penis with testes descended bilaterally. Tanner stage III.
Musculoskeletal: He has full range of motion to bilateral upper and lower extremities and neck.
Neurological: His motor exam is 5/5 power in upper and lower muscle groups.
He has no pronator drift. Sensory exam is intact with the ability to distinguish two-point discrimination. Gait is slightly ataxic. Upper and lower deep tendon refl exes are +2. Abdominal refl exes are symmetric and present.
Skin: Overall slight pallor. Soft-tissue swelling above right pinna in hair with a crusted lesion 3 cm × 2 cm in same area. There are no other cutaneous lesions present.
Impression
Based on the history of being struck with a hard object to the back of the head, and physical examination fi ndings of a soft-tissue swelling above right pinna with crusted lesion in same area, fever, dizziness, nausea, and
Chapter 9 Adolescent Male With Traumatic Brain Injury
105
vomiting, this patient is at risk for head trauma that is over forty-eight hours in time. Differential diagnoses taken into consideration include traumatic head injury, intracranial hemorrhage, intracranial hematoma, increasing intracranial pressure, headache, severe new-onset migraine, tension, thun- derclap headache with postauricular lesion, and mastoid pain. Concern for traumatic brain injury will guide evaluation in this setting, with emergent CT scan of the head.
It is also unclear whether this patient’s mother suffers from chronic headaches, which may be included in my differential diagnosis. There is lit- erature that suggests that mild traumatic head injury may trigger episodes of migraine headaches.
Post-traumatic headaches as well as post-traumatic syndrome can occur in patients after mild, moderate, or severe traumatic brain injury. Most of the patients’ symptoms clear within the fi rst 3 to 6 months. The headaches fall into the category of chronic tension-type headache as well as headaches compatible with migraine and are treated in a similar fashion (Linder, 2007).
CEBM, level 5.
This patient may also coincidentally have a fl u-like viral illness, causing his generalized malaise and emesis; however, this is considered less likely given history of head trauma.
ICD-9 Code: 432.9 Unspecifi ed Intracranial Hemorrhage. 346.9 Unspecifi ed Migraine. (D1,C3, PO A, C).
Plan
Therapeutics
IV with saline bolus and antiemetic ondansetron (Zofran) 5 mg intravenous (IV).
Diagnostics
Electrolyte panel, complete blood count (CBC), and CT scan of the head and brain.
The greatest risk to a patient with apparently minor traumatic brain injury (TBI) is an intracranial hematoma. The presence of this potentially fatal com- plication is often not apparent until clinical deterioration has occurred and recovery is endangered. Cranial computed tomography (CT) scanning has proven to be the most reliable diagnostic study for occult hematoma (Stein, Burnett, & Glick, 2006).
CEBM, level 2.
The precise mechanism of post-traumatic vomiting is unknown but it is likely that contact forces (impact) are less important than inertial forces (impulse)
in its etiology. Whereas symptoms such as loss of consciousness and post- traumatic vomiting are induced by head motion, skull fracture depends on contact forces. In most injuries the two phenomena occur together (Stein, Burnett, & Glick, 2006).
CEBM, level 2.
Counseling and Education
I explain to the patient and family with a Hmong interpreter that a head CT scan will allow me to assess if there is any abnormality in the brain after this patient’s injury, and the laboratory data will also support my diagnosis.
Working with Hmong people in medical settings raises a number of important cross-cultural health issues. For example, many Hmong people are apprehen- sive about the effects of invasive procedures. Specifi cally, patients may resist blood draws and lumbar punctures because tapping a fi nite amount of vital fl uids can invite negative consequences. In addition, Hmong often fear opera- tions because of the potential for impaired spiritual health. That is, souls may become frightened and leave the body during surgery, or the disfi gured body may doom the soul to dissevered misery in the next reincarnation (Her &
Culhane-Pera, 2004).
CEBM, level 5.
(D3, C1, PO B.)
Encounter Two
Diagnostic Test Results (35 minutes from initial evaluation)
Electrolyte panel and CBC were within normal limits.
I review the CT results with the pediatric radiologist. The CT scan reveals two metallic objects consistent with bullet fragments, one adjacent to the inner table of the mid right parietal calvarium measuring 3 mm in diameter, the other within the right occipital cortex medially measuring 6 mm in diameter. There is a beam hardening artifact from both bullet fragments, and a tiny density projects adjacent to the outer table of the calvarium that is probably a small bone chip at the same level. There is a minimally depressed calvarial fracture, presumably at the bullet entry site. There is overlying scalp swelling in that region consistent with what I assessed. There is also some posterior temporal lobe edema and air, presumably related to the bullet track because it could be followed from the entry site posteriorly and medially to the larger bullet fragment. There may be a small amount of right-sided tentorial subdural hemorrhage. There is no other intracranial hemorrhage, and there is very slight leftward midline shift without signifi cant ventricular compression.
Diagnosis
Gunshot wound to head. ICD-9 Code: 873.0.
Chapter 9 Adolescent Male With Traumatic Brain Injury
107
Plan
Counseling and Education
With the Hmong interpreter, I tell the family and patient that the blood tests are within normal limits; however, I am concerned about the CT scan.
I explain that the injury sustained was due to a bullet and I need to contact local authorities, a primary care provider, a neurosurgery team, and our child protection team (D2, C1, PO A).
The traditional Hmong religious perspective addresses questions pertain- ing to the cycle of birth and death, wellness and disease. The World of the Light and the World of the Dark exist side by side, so the mostly unperceived, transparent spirit world permeates everyday reality. Disruption of harmony and balance between souls in the real world and spirits in the spirit world culminates in disease. When one of a person’s three major souls wanders off, becomes lost, is ensnared by evil forces, or leaves the body to be reincarnated, then pain, suffering, and death will follow. Physicians should not underesti- mate the infl uence of a patient’s family when strategizing about a care plan.
Since Hmong belong to a patriarchal culture that values family-based deci- sion making, patients often turn to relatives to decide courses of action, and male clan leaders may be consulted if a disease is serious and the treatment plan is perceived as dangerous. As a source of insight and support for the patient, the clan’s primary responsibility is to the physical and spiritual health of family members (Her & Culhane-Pera, 2004).
CEBM, level 5.
Consultation
The family agrees to continue with the plan of care of contacting specialists and preparing for likely impending surgical intervention. I consult pediatric
Critical Appraisal
I know it is important that the family understand that further intervention is needed. Utilizing the concept of the LEARN model, I am able to integrate my assessment with their cultural beliefs for a shared decision-making process:
Listen with sympathy and understanding to the patient’s perception of the
•
problem
Explain your perceptions of the problem
•
Acknowledge and discuss the differences and similarities
•
Recommend treatment
•
Negotiate agreement
•
Source: Berlin & Fowkes, 2004
neurosurgery and the child protection team. The child protection team is con- sulted because of the nature of this patient’s diagnosis.
I upgrade the patient’s triage acuity and change to a trauma status as per our hospital protocol (D1, C4, PO A, B).
I order phenytoin (Dilantin) to prevent any seizure activity that may occur due to injury. I also notify local law enforcement (D1, C5, PO C).
Posttraumatic seizures contribute to secondary injury and have been observed to occur commonly in children with moderate to severe brain injury. Children differ from adults in exposures to injury, mechanisms of injury, and possibly in the pathophysiology of posttraumatic seizures. The child’s brain reacts differently to an acute insult, with a higher rate of signifi cant edema. Post- traumatic seizures may worsen ischemia and secondary injury by increasing cerebral metabolism and possibly by directly increasing intracranial pressure, contributing to poor outcomes. Prophylactic phenytoin has been shown to be effective in reducing early posttraumatic seizures in adults and may be effec- tive in children as well (Young et al., 2004).
CEBM, level 1.
Neurosurgery Consultation (50 minutes since initial evaluation)
The patient is evaluated by the pediatric neurosurgery team and we collabor- atively decide to admit this patient to the pediatric intensive care unit (PICU) after going to the operating room (OR) for bullet fragment removal. Since the gunshot penetrated the dura as noted on CT examination, the patient is scheduled for operative repair of the dura to prevent continued cerebral spi- nal fl uid (CSF) leak (D1, C5, PO A, B).
Counseling and Education (60 minutes since initial evaluation)
With the Hmong interpreter, I discuss the need for surgery to remove the bullet fragments. The family is anxious about surgery but understand that the bullet needs to be removed. The neurosurgeon obtains consent, and the patient is taken to the OR.
Critical Appraisal
Per our hospital policy, whenever there is a safety concern, whether it is in the home or in the community, the child protection team is contacted to aid in taking the history and to collaborate with law enforcement, The Child Protection Pro- gram Staff are experienced in working cooperatively with community physicians and agencies, law enforcement personnel, and the judiciary system to ensure the best outcome for children and their families.
Chapter 9 Adolescent Male With Traumatic Brain Injury
109
Encounter Three (inpatient day 1/postoperative day 1/POD1)
Patient has been transferred to PICU. When I visit, he is alone. He states that he no longer feels nauseated and is hungry.
Physical Examination
General: Asleep but easily arousable.
Vital signs: Temperature 98.9ºF, heart rate 66, respiratory rate 18, blood pres- sure 103/62, SaO2 99% room air.
Neurological: Patient remains alert and oriented × 3. Normal facial sensation.
5/5 musculoskeletal strength in upper and lower extremities. Sensation along radial, medial, ulnar, brachial, and interosseous nerves intact.
HEENT: Head dressing is clean, dry, and intact. PERRL 3 mm bilaterally with- out evidence of papilledema. His face is without droop. His tongue and uvula are midline. His neck is supple without cervical lymphadenopathy. Left upper fi eld unable to visualize my fi ngers during exam.
Cardiovascular: Heart rate is stable, without rub, click, or murmur. Peripheral pulses equal and strong +2.
Respiratory: Breath sounds are equal and clear bilaterally.
Abdomen: Soft nontender with bowel sounds in all four quadrants.
Genitourinary: Foley in place; urine output remains at > 1 cc/kg/hr.
Skin: Right parietal-temporal craniotomy dressing clean, dry, and intact.
Pain: Well controlled with morphine and/or acetaminophen with codeine.
Rates his pain 1/10.
Fluids, electrolytes, and nutrition: D5 0.9 normal saline with 20 meq/Kcl/L at 1.5 times maintenance. Patient is tolerating clear liquids and may advance his diet as tolerated.
Intraoperative Report Review
The procedure included a right craniotomy for incision and debridement of wound. Some foreign bodies and what appeared to be scalp tissue were incorporated into the opening. A small projectile fragment was found in the epidural space that was sent to pathology. The patient tolerated the procedure well and was transferred to the PICU after recovering in the postanesthesia care unit (PACU).
Impression
Patient is stable status post craniotomy. He is comfortable and is almost completely pain-free. Testing his fi elds of gaze, I note a positive left-upper- fi eld visual impairment that is a new fi nding post surgery and therefore will request ophthalmology consultation.
Plan
Remove Foley catheter.
•
Check electrolyte panel in the morning.
•
Check phenytoin (Dilantin) level.
•
Consult social work for discharge planning.
•
Consult neurology regarding need to continue phenytoin (Dilantin).
•
Consult ophthalmology for visual impairment.
•
Docusate (Colace) 100 mg by mouth twice to prevent constipation secondary
•
to opioid administration and change in diet.
Continue with IV phenytoin (Dilantin) 100 mg twice daily for prophylaxis of
•
seizure activity.
Continue IV cefazolin (Ancef) 1 g three times daily for prevention of infec-
•
tion postoperatively.
Continue with acetaminophen with codeine tablet orally every four hours
•
for pain.
Maintain intake and output.
•
Continuous pulse oximetry, vital signs.
•
Check weight daily.
•
Physical therapy for gait training and transfers.
•
Encounter Four (child protection consultation)
Both the patient and his older sibling are interviewed by the child protection team. They both deny ever feeling unsafe or scared in the park or at home, ever being hit or punched or otherwise hurt in their home, or ever receiving any punishment for bad behavior or poor grades.
After the evaluation, the child protection team and I determine that there is no need for Department of Children, Youth and Families involvement as there is no concern of supervision or medical neglect. This child has suffered from a signifi cant injury that may have long-term health effects. We also discuss the benefi t of counseling services post discharge. I will discuss the counseling options with social work.
Encounter Five (inpatient day 2/POD2)
Patient is awake and alert playing video games. Pain is well controlled with acetaminophen with codeine. Patient is tolerating a regular diet. Patient has ambulated out of bed to the bathroom and the hallway with physical therapy and occupational therapy (PT/OT).
Physical Examination
Vital signs: Temp 99.0ºF, heart rate 74, respiratory rate 20, blood pressure 106/74, SaO2 98% room air.
Neurological: Awake and alert × 3. Normal facial sensation and symmetry.
Able to distinguish two-point discrimination.