Case Study 2
A 13-year-old female restrained passenger of a vehicle was involved in an MVA at 60 mph on the highway. The vehicle experienced a frontal impact. The patient arrived in the ER with closed fractures of the left tibia and fibula with angulation, dislocation of the right ankle, multiple pelvic fractures, and femur fracture on the left side. Her BP is 92/54 with pulse of 130. What is your plan for this patient, and what are the considerations to prevent further morbidity? At what stage of development is she, and how does that impact her care WEEK 10 Differential Diagnosis and NSAIDS?
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Post an explanation of the differential diagnosis for the patient in the case study you selected. Explain which is the most likely diagnosis for the patient and why. Include an explanation of unique characteristics of the disorder you identified as the primary diagnosis. Then, explain a treatment and management plan for the patient, including appropriate dosages for any recommended treatments. Finally, explain strategies for educating patients and families on the treatment and management of neurologic and orthopedic conditions.
Read a selection of your colleagues’ responses.
Conduct an evidence-based drug search on the drug you selected and post an explanation of any possible issues. Are there any drug interactions? Any black box warnings? To what type of patient would you prescribe this medication?
Differential diagnosis includes multiple trauma, cardiogenic shock, and hypovolemic shock. The possible differential diagnosis for this patient is hypovolemic shock secondary to trauma-induced hemorrhage. The patient suffered multiple traumatic fractures including the tibia, fibula, pelvis, and femur. Injury to these bones can lead to substantial blood loss with pelvis alone contributing to about two liters of blood loss and femur 1.5 liters. Hemorrhagic shock is a condition that leads to decreased perfusion of tissues leading to inadequate delivery of nutrients and oxygen that plays a crucial role in the metabolism of cells. State of shock occurs when the cellular oxygen demand is higher than the supply (Fröhlich et al., 2016). The definition of shock becomes more difficult when it comes to the cellular level since the amount of oxygen that each cell requires is not the same (Gruen et al., 2016). This means that some cells, particularly those that have a high metabolic rate, have a higher demand for oxygen and thus are at higher risk of shock state. Therefore, clinicians have developed ways to correlate the cellular arrangements with physiology, clinical, monitoring and diagnostic aspects of shock WEEK 10 Differential Diagnosis and NSAIDS.
The clinical presentation in this case study is consistent with features of hypovolemic shock as a result of blood loss. First, the history of MVA with associated multiple fractures point towards massive blood loss. Secondly, the patient is hypotensive and has a high pulse rate which is consistent with the clinical features of shock. Increased pulse rate is as a result of compensatory mechanisms. When there is decreased blood volume, the baroreceptors detect this decrease and stretch and sends impulses to the nucleus tractus solitarius in the brainstem. The efferent limb of this neural reflex leads to increased sympathetic outflow to the heart and other organs. The response is tachycardia, vasoconstriction, shunting of blood away from the splanchnic circulation to the vital organs.
Treatment and Management Plan
Initial management plan of hypovolemic shock a trauma patient is a primary survey which encompasses ABCDE. The first step is to protect the airway and secure if is not patency through maneuvers such as jaw thrust and tilt. At the same time, it is crucial to stabilizing the cervical species to prevent any further deterioration of the spinal cord. The second step is definitive control, of the airway by giving the patient oxygen. The second step is to check circulation and securing two large bore venous access and sending a blood sample to the laboratory for grouping and cross-matching, blood gases analysis, complete blood count, urea, electrolyte, and creatinine serum lactate. Included in this stage is to control any external bleed. The next step is to assess disability which includes the neurological status whether they are alert, response to vocal or pain stimuli. Exposure and environment is the next step where the patient is undressed to asses for any other injury while maintaining optimum temperature. Adjuncts include to X-ray of the chest, abdomen and lateral cervical spine WEEK 10 Differential Diagnosis and NSAIDS.
Fluid replacement is the most important intervention in patients with hypovolemic shock. Systolic blood pressure of less than 90mmHg is associated with poor outcomes particularly in apatite with concomitant traumatic brain injury (Kalkwarf & Cotton, 2017). Early use of blood, is the optimum fluid of choice in patients with hemorrhagic shock. If blood is not available, Hartmann’s solution should be used which contains sodium lactate (Urbano et al., 2012). 0.9 percent is also another preferred alternative but caution should be taken since large volumes can lead to metabolic acidosis.
Pain can be treated with 25 mg of diclofenac sodium intramuscularly (Ahmadi et al., 2016). Diclofenac is an NSAID with both anti-inflammatory as well as antipyretic properties.
Definitive management encompasses surgery to fix the fractures. An orthopedic surgeon should be consulted to operate and reduce the fractures when the patient is stable.
Strategies for educating patients and Families
Educating the patient and the family regarding the patient’s condition can be achieved through a number of strategies. These include audio-visual methods, demonstration, print media, and verbal instruction. Verbal communication is perhaps the most effective strategy since patients receiving effective communication that is timely, complete and unambiguous enable to them to actively be involved in their care WEEK 10 Differential Diagnosis and NSAIDS.
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NSAIDS refers to non-steroidal anti-inflammatory drugs; a class of drugs indicated in the initial management of pain. Their mechanism of action is through inhibition of cyclooxygenase enzyme which prevents the formation of prostaglandins and thromboxane which are responsible for pain and inflammation. My chosen drug is diclofenac which is a nonselective cyclooxygenase inhibitor which has both anti-inflammatory and antipyretic properties. The drug is associated with two major issues of risks which are serious cardiovascular and gastrointestinal events. Diclofenac increases the risk of severe cardiovascular thrombotic events such as myocardial infarction and stroke (Wise, 2013). It also has an increased risk for gastrointestinal events such as severe ulceration, perforation, and hemorrhage. Therefore the drug is contradicted in patients with a history of myocardial infarction and those with gastric ulcers. The drug can be used to treat mild to moderate pain in patients with rheumatic conditions such as rheumatoid arthritis as well as pain those with trauma.
Ahmadi, A., Bazargan-Hejazi, S., Zadie, Z. H., Euasobhon, P., Ketumarn, P., Karbasfrushan, A., … & Mohammadi, R. (2016). Pain management in trauma: A review study. Journal of Injury and Violence Research, 8(2), 89.
Fröhlich, M., Driessen, A., Böhmer, A., Nienaber, U., Igressa, A., Probst, C., … & Mutschler, M. (2016). Is the shock index based classification of hypovolemic shock applicable in multiply injured patients with severe traumatic brain injury?—an analysis of the TraumaRegister DGU®. Scandinavian journal of trauma, resuscitation and emergency medicine, 24(1), 148.
Gruen, R. L., Brohi, K., Schreiber, M., Balogh, Z. J., Pitt, V., Narayan, M., & Maier, R. V. (2012). Hemorrhage control in severely injured patients. The Lancet, 380(9847), 1099-1108.
Kalkwarf, K. J., & Cotton, B. A. (2017). Resuscitation for hypovolemic shock. Surgical Clinics of North America, 97(6), 1307-1321.
Urbano, J., López-Herce, J., Solana, M. J., del Castillo, J., Botrán, M., & Bellón, J. M. (2012). Comparison of normal saline, hypertonic saline and hypertonic saline colloid resuscitation fluids in an infant animal model of hypovolemic shock. Resuscitation, 83(9), 1159-1165.
Wise, J. (2013). Diclofenac shouldn’t be prescribed to people with heart problems, drug agency says. BMJ: British Medical Journal (Online), 347 WEEK 10 Differential Diagnosis and NSAIDS.
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