clinical observations in a dying patient

I'd want to know what the patients current level of alertness is. It sounds like the patient is unconscious but from what you've said I'm not 100% sure. Also is it an open or closed head injury?

Ah okay, it's been a few years since I've worked in a hospital - but from memory pupils would be fixed/dilated and unresponsive to stimulus? Sorry, I'm not much of a help! Good luck!

Head injury can mean a lot of different things could be going on.

A trained medical professional, outside the hospital, would be noticing a drop in blood pressure. As the blood pressure drops, the points at which you can feel the beats of the heart disappear. At a certain point, all pulse points will not receive enough pressure to be felt. Breathing would probably become more erratic, and more effort would need to be exerted to breathe.

Skin color might become mottled, as blood supply is reduced. Response to stimuli would become more and more reduced.

Dying time would be on the slower side. The longer dying lasts, the more signs of decompensation you'll see.

Realize that dying can be reversed, and the medical professional is going to need a reason why this can't be reversed.

I'd have an entry would from the explosion behind the ear and right at the top of the brain stem. The swelling from this type of injury will eventually squeeze the brain stem and kill the patient. Damage from the entry of the debris from the explosion would be next to impossible to fix. Dying time would be in the six to twenty-four hour range. Pressure inside the brain is going to eventually kill the person, but the body will struggle for quite a while. Patient will be unconscious and unresponsive.

Best of luck,

Jim Clark-Dawe

Fixed and dilated pupils are a late sign, you would often get one eye affected and then the other. This is caused by pressure on the nerves supplying the eyes. Pupils should be equal in size, regular and responsive to light. Alteration in any of these is a bad sign.

As the Intra Cranial Pressure rises so does the blood pressure in order to try and keep the brain perfused, this goes along with a slowing and increasingly irregular heart rate. You also often get respiratory depression and the three of these together are known as Cushing's Triad. When ICP is significantly raised you often get abnormal posturing. If untreated, or if the damage is significant enough to render treatment irrelevant then death will follow soon afterwards.

Disclaimer: What I know about head injuries I know from the POV of an A&E nurse, I'm no neuro specialist.

If this is a decision being made on site as part of a pre hospital triage it wouldn't be too unreasonable to categorise them as likely to die regardless of treatment and therefore not worth taking to hospital.

crunchyblanket said:

The patient is indeed unconscious. It's a closed head injury - I was thinking along the lines of an epidural haematoma

Click to expand...

Assuming this is set in the UK there are a couple of scoring systems that might be useful to you. The first is CRAMS (Circulation, Respiration, Abdomen, Motor, Speech) - A general trauma scoring system that predicts survival fairly accurately. The second is GCS (Glasgow Coma Score) which is specific to consciousness and is used to assess head injury patients. They are fairly simple and readily available through a quick Google search. If you need a hand plotting your patient on them give me a shout.

With traumatic brain injuries, people who can't be tubed are going to have an irregular breathing pattern the closer the damage spreads the important parts of the brain. You can google 'Cheyne-Stokes' and "Biot's respirations' for a better description.

You can use it because a lay person observing it is going to think something along the line, "They're in pain/They're suffering/They don't want to die like this," etc. Because we think breathing is an expression of life, and quickened breathing often reflects those things. But in reality, it's just the brain shutting down. Once the brain gets to that point, we're talking imminent brain death. It's too damaged.

There may be contortions of the body, hands twisting inward. Again, it's the brain but to an observer it can be very distressing and interpreted as a sign of pain/distress.

I hope that helps! (even though, wow that was really depressing to type out.)

Some good advice above, but I'm with the character who wants to take the victim to the hospital. The victim's best chance of survival is to get there early, so he can be saved by a neurosurgeon.