General Data and Chief Complaint

• AA
• 11 yr old
• Female
• Roman Catholic
• Mandaue City
• Admitted for the 1st time in UCMed
• Fall

1
Prenatal, Natal, Postnatal History
• G1P0 25 yr old mother
• Unremarkable maternal history
• Had her prenatal check-ups done at LHC
• Delivered via NSD at home attended by a hilot
• Postnatal history-unremarkable
• Feeding: BF for the 1st 6 months then mixed feeding at 6 old
• Complimentary feeding started at 7 months old
• Birthrank 1/1

2
Immunization c/o LHC
• BCG 1
• OPV 3
• DPT 3
• HiB 3
• Hep B 3
• AMV 1
• MMR 1

3
Past Medical History
• Unremarkable
• No previous hospitalization or surgical procedure
• Non-asthmatic
• Non-diabetic
• Allergic to seafoods and chicken

4
Family History
• No known heredofamilial diseases

Personal and Social History

5
History of Present Illness
• NOI: Fall
• POI: Home (Lapu-Lapu)
• TOI: 9pm
• DOI: 9/17/2020

6
 PHYSICAL EXAMINATION
General Survey: Lethargic⇨Stuporous
Vital signs: T 36.5, PR 110 bpm ,RR 25, BP 110/70
mmHg, Weight: 25 kg
Skin: warm, good turgor
HEENT: Normocephalic, Anicteric sclerae, Pink
palpebral conjunctivae, + abrasion on left ear
C/L: Equal chest expansion, good air entry, Clear breath
sounds, no rales, no wheeze
CVS: Distinct Heart Sounds, Regular Rate and Rhythm,
no murmur
Abdomen: soft, nondistended
Extremities: warm, SPP, CRT <2s

7
 Neuro Examination
• GCS: 7 (E1 V1 M5)
• CN I- Not done
• CN II, - Pupils were 3mm and reactive Right pupil Non-reactive
6-7 mm and Left pupil sluggish 2-3mm
• CN III, IV,VI- (+) Doll’s eye
• CN V- Corneal reflex absent on both eyes
• CN VII- Not done
• CN VIII-Not done
• CN IX, X- + gag reflex
• CN XI- Not done
• CN XII- Not done
• Fundoscopy: Not done
8
 CBC

Lab Tests
Hemoglobin
Normal
11-16
Patient
15.6
Normal Patient
Clotting time 12s
Hematocrit 31-46% 43.3%
Bleeding time 11s
MCV 80-100
Protime 12.6s/86%/1.09
Platelet Count 140-440 386
aPTT 39.1s
WBC 5-10 32.46
Differential count HbsAg Non-reactive
Neutrophils 45-65 32 Blood typing O+
Lymphocytes 20-40 14
Monocytes 2-9 4
Eosinophils 0-6 0
Basophils 0-2 0

9
 Imaging

CT SCAN BP
Right temporoparietal
subdural/epidural hematoma
measuring approximately 1.7cm in
maximal thickness (25cc in vol)with
mass effect compressing the right
temporoparietal lobes and displacing
the midline structures to the left by
about 0.8cm. The right lateral
ventricle is compressed.

10
 Imaging
• Cervical Spine APL
• Straightening of the
cervical lordosis likely due
to muscle spasm.

11
MANAGEMENT
Mannitol 100cc IV Bolus q4h with AD 0.8 mkd
IVF with Sterofundin at MR
Ketorolac IVTT AD 1.2 mkd
Omeprazole IVTT AD 0.8mkd
Head of Bed elevated to 30 degrees
Scheduled for STAT RIGHT HEMICRANIECTOMY
For intubation
Referred to pedia neurologist and intensivist for co-management

12
 13mins-3 hours after admission:
S O A P
1 episode Vs: BP 110/70, HR 100s • Severe TBI sec to fall • Diazepam AD 0.2mg VTT given
of seizure Extremities: slightly cold, CRT<2 s, faint • Levetiracetam AD 20mkd q12H LD
pulses • Intubated with ET size 6.0 at level
S- GCS 7 (E1 V1 M3) 20mm
P- Anisocoric, dilated Right pupil 6- • Attached to Cardiac Monitor
7mm Non-reactive, Left pupil sluggish • Attached to mech vent:
reactive 2-3mm AC mode
E- absent FiO2 40%, TV 200
R- no spontaneous breathing Rate 16, PEEP 5
M- flexion to pain • Dobutamine drip AD 10mcg/kg/hr
Reflexes: • Cefuroxime AD 90mkD
(-) Doll’s eye • FBC and NGT inserted
(-) Babinski • Urine output monitored hourly

13
 Post- Op 6-23 hours
S O A P
Spontaneous Vs: BP 84-/40-98/60, HR 100s, O2 sat 100% •Severe TBI sec to fall •NE 2mg+50cc NSS @ 6.7cc/hr
movement of Extremities: slightly cool extremities CRT<2 s, •Right Frontotemporal •Dexmedetomedine 2mmg in 50cc PNSS @
extremities, SPP Epidural Hematoma 2.3cc/hr (0.3mhm)
localizes pain S- GCS 8 (E2 VT M5) •S/P Right frontotemporal •Dobutamine discontinued
JP drain noted P- Pinpoint pupils craniotomy, evacuation of •Citicoline AD 12 mkd
with 50cc E- eye opening to pain hematoma •Oxacillin 240 mkD
R- + spontaneous breathing on MV • Paracetamol IVTT AD 18mkd q6h
M- 5/5 on both upper extremities, 3/5 on • Tranexamic acid 12mkd q8h x 3 doses
right lower extremity, 2/5 on left lower •Transfused with 1 unit of PRBC
extremity
Reflexes:
Hyperactive reflexes
(+) Doll’s eye
(-) Corneal reflex
(-) Babinski
SGPT: 23
Na/K: 140/4.7
Creatinine: 0.42
ABG: 7.4/38/110/24.3/BE 0.6/96%

14
 Post- Op Day 1-3
S O A P

Febrile episodes Vs: T 38.2 , BP 90/60-100/80, HR 100s • Severe TBI sec to fall • Paracetamol 15 mkd per NGT
noted. HEENT: + clean, dry intact dressings, + • Right Temporal Epidural • Citicoline shifted to PO
Follows abrasion left ear Hematoma • Cellufresh eye drops 2 drops OU 4x a day
commands with Extremities: warm, CRT<2 s, SPP • S/P Right • Mech vent settings adjusted:
partial eye S- GCS 10 ( E3 VT V6) frontotemporal AC Mode
opening to P- Anisocoric, non-reactive, dilated R craniotomy, evacuation FiO2 decreased by 3% every 3 hours until
tapping pupil 6-7mm, L pupil sluggish reactive 2- of hematoma 30%
3mm RR decreased by 1 cpm every 3 hours until
E- Right eye frozen, Left eye with Left 16 cpm to alternate with decrease FiO2
Lateral Rectus Palsy
R- + spontaneous breathing
M- 5/5 on both upper extremities, 3/5
on right lower extremity, 2/5 on left
lower extremity

15
 POST-OP day 4 (PACU)
S O A P

Awake, alert, Vs: BP 90/60-100/60, HR 85-99 • Severe TBI sec to fall • Mech vent settings shifted to SIMV Mode
follows HEENT: + clean, dry intact dressings, + • Right Temporal Epidural • FiO2 25%, BUR 10, PEEP 2
commands abrasion on left ear Hematoma • Dexamethasone with AD 0.2 mkd
Extremities: warm, CRT<2 s, SPP • S/P Right
S- GCS 11 (E4 VT M6) frontotemporal
P- Isocoric 2mm brisk in reaction both craniotomy, evacuation
eyes of hematoma • Extubated
E- Right eye frozen, Left eye with Left • Shifted to nasal cannula at 2lpm
Lateral Rectus Palsy • Epinephrine neb 1ml+4ml NSS X 2 doses
R- spontaneous • IV Paracetamol discontinued
M- 5/5 on all extremities • Mupirocin ointment TID on left ear wound
• Feeding restarted
ABG (1 hour post-extubation)
Ph 7.46, PCO2 36.6, PO2 134, HCO3
26.6, BE 3, SaO2 99%

16
 Post-Op Day 5-6
S O A P

Awake, conscious, coherent, Vs: BP 90/60-100/60, HR 85- • Severe TBI sec to fall • Trans out to regular room
follows commands. 99 • Right Temporal Epidural • NGT feedings – HOLD
Complains of intermittent HEENT: + Clean, dry and Hematoma • Ondansetron 0.16 mkd per NGT
right frontotemporal intact dressings, + healing • S/P Right • Paracetamol continued
headache with pain score of wound on left ear frontotemporal • Omeprazole IVTT 0.8mkd
6/10. Extremities: slight cool, craniotomy, evacuation • D5LR increased to MR + mild
Complains of back pain. CRT<2 s, spp of hematoma
Dizziness reported. S- GCS 15 (E4 V5 M6)
Vomiting x 6 episodes P- Isocoric 2mm brisk in
amounting to 240ml for the reaction both eyes
whole episode E- Right eye Full Visual
fields, Left eye lateral rectus
palsy
R- spontaneous breathing
M- 5/5 on all extremities
Serum Na/K: 139/ 3.6

17
 Post-Op Day 7-10
S O A P

Awake, conscious, Vs: BP 90/60-100/60, HR 85-99 • Severe TBI sec to fall • Oxacillin D8 completed and shifted to
coherent, follows HEENT: + Clean, dry and intact • Right Temporal Epidural Cloxacillin with AD of 80mkD
commands. dressings, + healing wound on Hematoma • Cefuroxime D8 completed
Complains of intermittent left ear • S/P Right • O2 DC
right frontotemporal Extremities: slight cool, CRT<2 frontotemporal • NGT removed
headache with pain score s, spp craniotomy, evacuation • Started on general liquids⇨ full diet
of 2/10. S- GCS 15 (E4 V5 M6) of hematoma • FBC removed
Complains of back pain. P- Isocoric 2mm brisk in • Paracetamol continued q6h PRN for pain
Occasional Dizziness reaction both eyes • Referred to ophthalmologist for evaluation
reported. E- Right eye Full Visual fields, • Continued Cellufresh eye drops
No recurrence of Left eye lateral rectus palsy
vomiting. R- spontaneous breathing
(+) blurring of vision M- 5/5 on all extremities

UA-Negative

18
 Post-Op Day 11
S O A P

Awake, conscious, Vs: BP 90/60-100/60, HR 85-99 • Severe TBI sec to fall • Cleared for discharge
coherent, follows HEENT: + Clean, dry and intact • Right Temporal Epidural
commands. dressings, + healing wound on left Hematoma • Take home medications:
Complains of ear • S/P Right
intermittent right Extremities: slight cool, CRT<2 s, frontotemporal • Paracetamol 250/5 7.5ml q6h PRN for pain
frontotemporal spp craniotomy, evacuation • Levetiracetam 100mg/ml 5ml BID
headache with pain S- GCS 15 (E4 V5 M6) of hematoma • Citicoline 500mg 1 tab q12h
score of 2/10. P- Isocoric 2mm brisk in reaction • Cellufresh eye drops 2 drops OU
(+) blurring of vision both eyes • Mupirocin ointment on Left ear TID
E- Right eye Full Visual fields, Left
eye lateral rectus palsy
R- spontaneous breathing
M- 5/5 on all extremities

19
Discharge Diagnoses
Severe Traumatic Brain Injury secondary to Fall
Right Temporal Epidural Hematoma
S/P Frontoparietal Craniotomy, Evacuation of Hematoma

20
Thank You

21