Motorcycle Accident: Facial Nerve Examination

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Questions and Answers

What was the primary mechanism of injury reported in the case scenario that led to the patient's unconsciousness?

  • Fall from a motorcycle (correct)
  • Assault with a blunt object
  • Fall from a height
  • Motor vehicle collision

Upon arrival of the ambulance, what was the patient's initial level of consciousness?

  • Regained consciousness (correct)
  • Fluctuating level of consciousness
  • Responsive only to painful stimuli
  • Completely unresponsive

Which of the following behavioral presentations did the patient exhibit upon regaining consciousness at the accident scene?

  • Euphoric and disoriented
  • Agitated and confused (correct)
  • Calm and cooperative
  • Lethargic and withdrawn

What critical piece of safety equipment was noted to be absent at the scene of the motorcycle accident?

<p>Helmet (B)</p> Signup and view all the answers

What was the approximate time duration between the incident and the patient's arrival at the nearest hospital?

<p>40 minutes (A)</p> Signup and view all the answers

Upon arrival at the hospital, what device was already in place to manage potential spinal injury?

<p>Cervical collar (B)</p> Signup and view all the answers

What type of intravenous access was established by paramedics in the pre-hospital setting?

<p>Peripheral IV access (C)</p> Signup and view all the answers

During the secondary survey, decreased wrinkles on the right forehead, difficulty closing the right eye, and deviation of the mouth to the left suggest dysfunction of which cranial nerve?

<p>Facial nerve (CN VII) (A)</p> Signup and view all the answers

Loss of sensation in the lower third of the face on the right side is most likely related to the branch of which cranial nerve?

<p>Mandibular branch of Trigeminal nerve (V3) (A)</p> Signup and view all the answers

Impaired extraocular movement of the right eye suggests potential injury to which cranial nerve(s)?

<p>Oculomotor, Trochlear, or Abducens nerves (CN III, IV, VI) (A)</p> Signup and view all the answers

A 'normal eFAST examination' typically assesses for free fluid in which of the following anatomical locations?

<p>Pericardial sac, pleural spaces, and peritoneal cavity (C)</p> Signup and view all the answers

According to the radiology report, a linear fracture extends from the left frontal bone into the left squamous temporal bone. This fracture is described as extending into which cranial fossa?

<p>Middle cranial fossa (B)</p> Signup and view all the answers

Fractures involving the sella turcica are significant because of their proximity to which endocrine gland?

<p>Pituitary gland (D)</p> Signup and view all the answers

Evidence of blood within the middle ear cavity, as noted in the radiology report, is most indicative of a fracture involving which bone?

<p>Temporal bone (B)</p> Signup and view all the answers

A right orbital floor blow-out fracture with herniation of orbital fat into the maxillary sinus would most likely result in which clinical sign?

<p>Enophthalmos (B)</p> Signup and view all the answers

What type of intracranial hematoma is described as a 'large biconvex epidural haematoma' in the radiology report?

<p>Epidural hematoma (C)</p> Signup and view all the answers

Subfalcine herniation, mentioned in the radiology report, involves the displacement of which anatomical structure?

<p>Cingulate gyrus (B)</p> Signup and view all the answers

The patient's GCS upon arrival in the Emergency Department is calculated based on the findings: 'drowsy, no spontaneous eye opening but opens to pain, utters inappropriate words, flexion/withdrawal to pain'. What is the patient's GCS score?

<p>10 (C)</p> Signup and view all the answers

Anisocoria, with the right pupil 3mm and left pupil 4mm, and a sluggish reaction of the left pupil to light suggests which of the following?

<p>Left-sided oculomotor nerve compression (B)</p> Signup and view all the answers

A blood pressure of 170/100 mmHg and heart rate of 65 bpm in the context of a head injury is most concerning for:

<p>Cushing reflex (D)</p> Signup and view all the answers

Temporary hyperventilation to an EtCO2 of 30mmHg is used in head injury management primarily to achieve:

<p>Decreased intracranial pressure (B)</p> Signup and view all the answers

Mannitol (20%) is administered in head injury management for what primary pharmacological effect?

<p>Osmotic diuresis (A)</p> Signup and view all the answers

Why would a patient with facial nerve palsy, as in this case, require eye drops?

<p>To prevent corneal dryness and ulceration (A)</p> Signup and view all the answers

In the 'Management Decision-Making' flowchart, what is the primary factor that determines whether to proceed with 'Burr hole evacuation or craniectomy/otomy' versus 'Retrieval'?

<p>Transfer time to tertiary care unit (C)</p> Signup and view all the answers

The patient's sodium level is 158 mEq/L (Reference range: 135-145 mEq/L), plasma osmolality is 302 mOsm/kg (Reference range: 275-295 mOsm/kg) and urine osmolality is 243 mOsm/kg (Reference range: 300-900 mOsm/kg). These findings are most consistent with which condition?

<p>Diabetes insipidus (B)</p> Signup and view all the answers

Flashcards

Glasgow Coma Scale (GCS)

Brief neurological assessment to measure level of consciousness.

Epidural Hematoma

Collection of blood outside the blood vessels, but within the skull.

Anisocoria

Difference in pupil size between the eyes.

Mass effect

Enlarged or swollen.

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Herniation

Forcing of brain tissue from one intracranial compartment to another.

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Positioned in 30°Head up

Elevating head 30 degrees

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IV Mannitol

Medication used to decrease pressure in the brain.

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Temporarily hyperventilation

Hyperventilation to achieve an EtCO2 of 30mmHg for 5-10 minutes

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Temporal burrhole procedure

Small hole drilled into the skull

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Facial Nerve Palsy

Inability or difficulty in closing the eye.

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Intubation

Airway management and ventilation

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Study Notes

  • A middle-aged male was found unconscious on the roadside embankment after reportedly falling from their motorcycle.
  • Emergency services were alerted by a passing driver.
  • The patient had regained consciousness upon the ambulance's arrival but exhibited irritability, aggression, and confusion.
  • The patient communicated and complied with simple commands and displayed purposeful movement in all limbs.
  • Vital signs were within the normal range.
  • There was no evidence of a helmet.
  • The patient was brought to the nearest hospital approximately 40 minutes later.
  • The patient was in a cervical collar, and paramedics had obtained IV access.
  • There are decreased wrinkles on the right forehead, difficulty closing the right eye, and deviation of the mouth to the left.
  • There is loss of sensation in the lower third of the face on the right side.
  • There is possible loss of sensation on the upper lip, teeth, and gums on the right.
  • The patient has impaired extraocular movement of the right eye.
  • No other significant injuries detected on head-to-toe examination and log roll.
  • The eFAST examination was normal.
  • A linear fracture extends from the left frontal bone into the left squamous temporal bone.
  • This fracture extends into the middle cranial fossa.
  • Fractures involving the Sella turcica and sphenoid sinus are observed.
  • Fractures involving the right foramen ovale and the otic capsule of the right petrous temporal bone are noted, with evidence of blood in the middle ear cavity.
  • There is a right orbital floor blowout fracture with herniation of orbital fat into the maxillary sinus.
  • A large biconvex epidural haematoma is present in the left frontotemporal region, causing mass effect, midline shift, and sub-falcine herniation.
  • Neurosurgical consultation was done over the phone; CT scans were reviewed, and the patient was requested to transfer to the tertiary care unit (1.5 hours driving distance).
  • In the ED, the patient appeared drowsy with no spontaneous eye-opening but opened eyes in response to pain.
  • The patient utters inappropriate words in response to questioning and exhibits flexion/withdrawal in response to painful stimuli.
  • Blood pressure: 170/100.
  • Heart rate: 65.
  • Neurological: Anisocoria with the right pupil 3mm and the left pupil 4mm.
  • The left pupil has a sluggish pupillary reaction to light.
  • The patient is sedated for muscle relaxation.
  • The patient is intubated and temporarily hyperventilated to an EtCO2 of 30mmHg for 5-10 minutes (stop if signs resolve).
  • The patient is positioned in 30°Head up.
  • The cervical collar is removed, and restrictive endotracheal tube ties are loosened.
  • IV mannitol 20%: 1g/kg over 20 mins.
  • The patient is prepared for a Temporal burrhole procedure.
  • The patient is immediately booked into the theatre and within minutes an emergency evacuation of hematoma using the burr hole procedure.
  • The patient was transferred to Neurosurgical intensive care.
  • After a week, the patient is clinically improved except for the facial nerve palsy and will still require eye drops in the right eye.
  • Over the first 24 hours in the hospital, the patient is producing urine at a faster rate than IV fluid being infused.
  • Results:
    • Na+: 158 (Reference Range: 135-145 mEq/L)
    • Plasma osmolality: 302 (Reference Range: 275-295 mOsm/kg)
    • Urine osmolality: 243 (Reference Range: 300-900 mOsm/kg)
  • On initial examination in the emergency department, the patient complains of neck pain, dizziness, and light headedness, and the peripheries are abnormally warm.
    • Blood pressure: 86/54 mmHg
    • Heart rate: 53 Beats per min
    • Temperature: 36.8°C

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