T.J. is a 43-year-old white man who

T.J. is a 43-year-old white man who was the driver of a motorcycle that ran into an automobile. He was sedated, paralyzed, and intubated by paramedics at the scene before transport by helicopter. He was brought to the emergency department with a diagnosis of closed head injury with skull fracture. Subjective Data · He was reportedly unresponsive at the scene with a Glasgow Coma Score = 3, hypotension, tachycardia, and shallow irregular respirations Objective Data At the Scene · Unresponsive with obvious deformity to the left side of the skull · Respirations were shallow and irregular · O2 saturations ranged from 90-95% · Systolic blood pressure ranged from 50 to 80 mm Hg · Heart rate ranges from 100 to 130 bpm In the ED · Right pupil 4 mm nonreactive; left pupil, 3mm nonreactive · Glasgow Coma Score = 3 · Hypotension and tachycardia continued in spite of fluid resuscitation Diagnostic Studies · CT of the head positive for left skull fracture, left subdural hematoma, bilateral intraventricular and subarachnoid hemorrhage, and cerebral edema. · CT of the abdomen/pelvis showed a lacerated liver, multiple infarcts Question: A Head-To-Toes Notes for this patient.

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