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Forehead wound, active bleeding, nasal and oral bleeding. Delay of two hours a mistake?

DOCTOR OF THE MONTH - Nov 2013
Nov 2013
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We need to review the responsibility of hostel nurse. The story is that a mentally handicapped client was found with the following condition: Right forehead 1cm supefericial wound with active bleeding, nasal and oral bleeding which stopped after a while. Hostel nurse send the client to emergency after two hour of the incident. Was the delay of 2 hours a very great mistake?
I checked mayoclinic website and CDC website of when we should seek medical immediately after head injury, for the client was alert and no vomiting or alter of conscious level, for safety sake, the nurse send him to emergency department, but 2 hours later.
Posted Wed, 26 Sep 2012 in Brain and Spine
 
 
Answered by Dr. Sudhir Kumar 2 hours later
Thank you for contacting Healthcare Magic.
I have noted the details of the case.
This case pertains to scap laceration with nasal and oral bleeding (which had stopped).
I would agree that in cases of head injury, one should be taken to the emergency room (ER) at the earliest. This is so as there is a "golden hour" period in these cases. If treatment is started in the golden hour (first hour after the injury), the chance of successful recovery is the highest.
However, in the current case, there seems to be no definite evidence of head injury. Definite signs of head injury include severe headache, vomiting, decreased alertness, fits, etc.
In this case, though it would have desirable to take the patient to ER at the earliest; I would not find too much fault with the two-hour delay.
Please get back if you have any more queries.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant Neurologist
Apollo Hospitals, Hyderabad
Above answer was peer-reviewed by
 
Follow-up: Forehead wound, active bleeding, nasal and oral bleeding. Delay of two hours a mistake? 1 hour later
Dear Dr XXXXXXX
Thankyou very much for your prompt answer. It is because the emergency blamed our late. However, the victim was also delayed for more than one hour plus in the emergency room before seeing the doctor.
Besides, I forget to tell there was witness (also a mentally handicapped) client said the case was pushed by another client. The victim had racoon eyes. Netherless, no fracture base of skull was found, and the doctor said the nasal bleeding was not related to head injury.
We need to evaluate whether the delay in hostel was a very serious mistake or forgivable.
Please give your expert advice.
Thanks a lot!
 
 
Answered by Dr. Sudhir Kumar 29 minutes later
Hi,
Thank you for getting back.
I have gone through the above details.
Based on the circumstances and the clinical details of the patient, I think there was a mild delay on the nurse's part. However, I feel it is a minor error and the delay in the hostel can be forgiven.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX Consultant Neurologist
Above answer was peer-reviewed by
 
Follow-up: Forehead wound, active bleeding, nasal and oral bleeding. Delay of two hours a mistake? 11 hours later
Dear Dr XXXXXXX

Thankyou again for your professional judgement, however, can we say that people with mentally handicap usually have very fragile vessel ?
Actually the client in ER had CT brain 6 hours after the accident. Slightly intracranial bleeding and fracture of skull was found. Doctor said that the haematoma can be reabsorbed itself and the fracture was not serious and let it heal itself. After observation for 2 days in hospital, the client was sent back to hostel. What should we observe for this case? Will the bleeding reoccur spontaneously? Should the client wear a helmet to prevent further injury? We put him in a single room to prevent any further injury. How long should we wait to stop this "isolation"?
We do not want to discipline anyone who is not guilty but we also need to protect our mentally client. We need your opinion to follow up this issue fairly.
 
 
Answered by Dr. Sudhir Kumar 48 minutes later
Thank you for getting back.
I am glad that hematoma was minor and we can expect complete recovery in this case.
Mentally handicapped people do not have more fragile vessels. Their risk of skull fracture and brain hemorrhage after a trauma is similar to people withot mental handicap.
The duration of isolation can be for upto 4-6 weeks by when we can expect complete improvement. There is no need of using helmet as it is not practical (it would be needed to be worn by everyone to prevent an extremely uncommon injury).
There is almost no chance of rebleeding in this case. In this case, you should observe for severe headache, vomiting, decreased alertness, fits, etc.
Best wishes,
Dr Sudhir Kumar MD DM (Neurology) XXXXXXX consultant neurologist
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