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State of confusion

1) Interpreting the presented scenario, one can say that the 12-year old child experienced an episode of grand mal seizure. Grand mal seizure is caused by abnormal electrical activity in the brain cells. It usually involves the whole body and is characterized by muscle rigidity, violent rhythmic muscle contractions, and loss of consciousness. Generally, grand mal seizure has two stages: the tonic phase and the clonic phase. In the tonic phase, the person becomes unconscious and the muscles contract, causing him or her to fall down.

It is then followed by rigidity all over the body. Clonic phase follows which is characterized by alternate flexing and relaxing and convulsions may last for a minute or two. It is often accompanied by other symptoms such as aura. Aura is defined as a heightened sensory activity or sudden perceptual disturbance that usually precedes a seizure. It is often characterized by numbness, perception of a strange light or unpleasant odor, and sensitivity to sounds. Other symptoms include postictal symptoms.

With grand mal seizure, the patient usually has an amnesia about the episode, state of confusion, or deep sleep. In the scenario, the patient underwent a series of exam like the x-ray, lumbar puncture and electroencephalogram (EEG). Findings in these laboratory tests are said to be normal. These tests are administered in order to rule out the cause of the seizure. Negative results in lumbar puncture suggests that the patient’s seizure is not caused by encephalitis or meningitis.

Negative x-ray results would mean that the seizure is not caused by any traumatic head injuries. EEG is normal because it is between the seizure episodes. Although it is normal, one cannot exclude epilepsy as a cause. However, at some time, most epilepsy patients have abnormal EEG discharges. 2) Epidural and subdural hematoma are two serious complications of a head injury. They are both considered as dangerous blood clots in the brain. The difference between them is their point of reference with respect to the dura mater.

The epidural hematoma occurs on top of dura mater, usually between the dura and the bone. It is considered to be the most serious complication of any kind of head injury. Meanwhile, a subdural hematoma occurs beneath the dura mater. In here, the blood deposits between the dura and the arachnoid meninges. Epidural hematoma and subdural hematoma occur due to rupture of different blood vessels. In epidural hematoma, the blood vessel affected is the middle meningeal artery, an artery responsible for the blood supply to the meninges of the brain.

With subdural hematoma, bleeding results from injured veins which is responsible for draining blood away from the brain. Since veins have lower pressure than arteries, bleeding and hematoma formation in subdural hematoma progresses slowly than those of epidural hematoma. Symptoms of epidural hematoma may occur with minutes or hours such as increase in intensity and frequency of headache, decrease in the level of consciousness, and some focal neurologic deficits such as hemiparesis. Those of subdural hematoma can be delayed from 24 hours up to a week.

Computed tomography (CT) scan images of the two hematoma also vary. Blood in an epidural CT scan has limited space to spread because the blood has to make extra effort in conquering the tight connection between the skull and the dura mater. In contrast, blood in subdural hematoma can freely spread because of the loose space beneath the dura mater. As bleeding progresses, intracranial pressure (ICP) increases. However, the body compensates to prevent an increase in ICP through the efflux of cerebrospinal fluid.

As ICP increases, cerebral perfusion pressure (CPP) decreases. If CPP decreases below 50 mmHg, the brain may become ischemic which may trigger secondary mechanisms of injury, causing further damage, further edema, and further increase in ICP. Signs and symptoms of increased ICP would include headache, vomiting, and altered level of consciousness. It will come to a point wherein the skull cannot sustain the continuously rising ICP, thereby depressing some parts of the brain and eventually leading to herniation.

One type of herniation is the transtentorial herniation, which compresses the upper brain stem and the thalamus. Considering that the thalamus is the one responsible for arousal, level of awareness, activity and consciousness, herniation in this part may result in impaired consciousness. If brain stem is affected, client will show abnormal breathing patterns and fixed pupil dilation. If presented with a situation of choosing which among the two needs immediate treatment, the answer is epidural hematoma. Since bleeding occurs rapidly in this type of hematoma, emergency surgery is needed.

The surgery will evacuate the hematoma thereby decreasing the ICP. If left untreated, epidural hematoma will be fatal. ICP will continue to increase and may cause edema. The edema formation will further increase the ICP and may later cause herniation. The herniation will then compress some parts of the brain and will lead to symptoms like altered level of consciousness, abnormal posturing, and paralysis. If the affected part of the brain is the respiratory center, it may cause respiratory arrest which can lead to death.

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