Case of the Month
May 2008

76-year-old male – decreased LOC

Dispatch
Your BLS unit is dispatched a 76-year-old male who has a decreased level of consciousness.

While en route the dispatcher notifies you that the patient is in an adult family home and has been lethargic most of the day.

En route your crew discusses the following considerations:

• Reasons decreased level of consciousness
• Geriatric issues

Scene Size-up
Your team arrives at the scene and is met at the front door by a member of the Miller’s Manor Adult Family Home staff caregiver. As she leads you back to the patient’s room she reports that Mr. Cholak is normally mobile with the help of a walker and despite some dementia he is typically very alert. Earlier this morning gradually he became more lethargic and weaker. She also states he has Do Not Resuscitate (DNR) paperwork and the family does not want any “heroic” measures taken.

Initial Assessment
You find the patient in bed lying on his back with his eyes closed. His skin appears to have good color; he is warm and dry. When you feel his wrist for a pulse he opens his eyes slightly, looks at you, moans quietly, and closes his eyes shut. The caregiver immediately states “See? That’s not like him!“ The patient’s pulse is strong at about 60. You determine he is SICK because of altered LOC and confirm dispatch of the ALS unit.

Initial Treatment
You initiate oxygen therapy and obtain a blood sugar reading (90 mg/dl). You also perform a quick “blood pat-down” to check for external bleeding and notice a small lump and a little dried blood on the back of his head. The caregiver reports that the patient fell while walking through the home yesterday. One of your team members is sent to bring in the gurney while vital signs are obtained.

Vital Signs

• Respirations                        18
• Pulse                                 60
• Mental status                      Very lethargic
• Pulse oximetry                     98% on cannula
• Blood sugar                         90
• Blood pressure                     196/P

Further Evaluation and Treatment
One of your team members requests a copy of the patient’s records and asks the caregiver about the patient’s recent medical history. It is discovered that the he has a history of hypertension and transient ischemic attacks. The patient takes atenolol for blood pressure control and Coumadin (warfarin) to help prevent further TIAs and CVAs.

You further investigate the caregiver’s report that the patient had fallen. She states that he was walking and tripped on a rug in the hallway. Before hitting the floor he struck the back of his head on the wall; however, he seemed fine after the fall. The patient did not act abnormally until after waking this morning. After hearing this immediate history you perform a trauma exam and find a small lump on the back of his head. The rest of the physical exam is unremarkable. Due to the fall and potential for neck or back injury, you decide to place the patient on a backboard with a cervical collar for transport. The ALS unit is updated and soon arrives at the scene.  The patient’s DNR form is found and confirmed.

The ALS unit arrives and initiates an IV. Transport is accomplished without incident.

At the hospital a CAT scan reveals a subdural hematoma. An x-ray of the neck reveals a stable C-3 fracture. Due to the patient’s age and general health the emergency department team decides to contact the patient’s family prior to pursuing further treatment.

What is a Subdural Hematoma?
A subdural hematoma (SDH) occurs when a pocket of blood develops between the dura (the outer protective covering of the brain) and the arachnoid (the middle layer of the meninges). This most frequently is due to head trauma but can also occur spontaneously. The bleeding is almost always the result of a tear in a vein. The bleeding can be either gradual or rapid. Therefore the signs or symptoms after blunt force head trauma can surface in minutes or take days to manifest. As the pocket of blood expands, pressure builds on the adjacent brain tissue and the patient may develop neurological signs and symptoms including:

• Headache (constant or fluctuating)
• Sleepiness
• Dizziness
• Decreased level of consciousness
• Seizure
• Other neurological manifestations
• Coma
• Death

Some of the risk factors that can increase the possibility and extent of a SDH include:

• Head injury
• Age (young or elderly)
• Anti-coagulant medications (such as warfarin or aspirin)
• Long term alcohol use

Treatment in the field should focus on the ABCs and preventing further injuries. Since head trauma often precedes this type of injury, neck and spine precautions should be taken. Rapid transport to an appropriate facility is also critical in the treatment of any patient who is displaying evidence of a severe head injury.

Emergent hospital treatment for this insult can include drilling in the blood pocket to relieve the pressure, or surgically opening the skull to remove the clot and stop the bleeding.

Subdural Hematoma
eMedicine (external website)