History of Present Illness:  A police officer who was involved in a head on collision with a car and subsequently ejected from his motorcycle.  He was wearing a helmet but sustained a large head injury to the right side and arrived via helicopter in cardio-respiratory distress.

Past Medical History: None noted

Social History:  Negative for tobacco or ethanol.

Physical Exam:  Revealed a 33-year old male with fixed/unresponsive eyes and profuse nasal bleeding.  He was in sinus tachycardia (heart rate 161) and did not have bowel sounds.  He was in cardio-respiratory distress with a blood pressure of 57/30 and was intubated on arrival.

Pertinent Lab Values include CO₂ 16 mEq/L (normal 22-31); Creatinine 1.5 mg/dl (normal 0.5-1.1_; Hgb 9.4 gm/L (normal 11.5-16) hct 26.9% (normal 34-47); Platelets 75 k/ul (normal 150-500); PT 20.3 sec (normal 11-14) PTT 51.9 sec (normal 23-37) INR 1.8 sec; Arterial Blood Gas Values: pH 7.25 pCO₂ 42.5 pO2 49.2 O2 18.4%

Hospital Course:  Patient was taken to CT and findings were that there was parenchymal edema with loss of gray/white zone and downward herniation, as well ans multiple pulmonary contusions.  The patient in route from CT was administered Na bicarbonate, Calcium 1g, and epinephrine IV.  He received 4 transfusions of fresh frozen plasma and red blood cells.  He was transferred to nuclear medicine for a brain scan, where he was administered 33 mCi of Tc-99m Ceretec.  Anterior and lateral projections were taken and results revealed no evidence of brain activity.  The patient was pronounced dead at 11:15 pm and kidneys and heart valves were removed for donation.

In summary, we have a 33-year-old male who presented with a severe closed head injury and subsequently died from the injury at 11:15 on the same day admitted.

For more information about giving the gift of life see http://www.organdonor.gov/

 

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