Approach To A Patient Who Presents To ER After A Fall. (Case Study)

A 52-year-old male presents to your ED via ambulance complaining of a headache after a fall. He was working and fell approximately 10 feet. He notes no injury except for head and neck pain. A quick survey reveals that he has a BP of 128/86, pulse 100, and respiration 12. There was no loss of consciousness at the scene. He “saw stars” and was clumsy, dazed, and
slow at the scene without any focal neurologic deficit. He is now back to his baseline.

A concussion is defined as:
A) Any neurologic symptoms (e.g., clumsy, dazed, or slow) after head injury.
B) Loss of consciousness followed by return to baseline.
C) Loss of consciousness with continued neurologic symptoms.
D) Requires confusion after head trauma regardless of whether the patient lost consciousness or not.
E) Any traumatic injury to the head.

Answer And Discussion
The correct answer is “A.” Any neurologic symptoms (e.g., clumsy, dazed, or slow) after head injury.

A concussion is defined as any neurologic symptom after head trauma. Note that a concussion does not require a loss of consciousness. For this reason, “B” and “C” are incorrect.
“D” is incorrect because manifestations of concussion are not limited to confusion but also include protracted vomiting, transient amnesia, slowed mentation, “dizziness,” and other neurologic symptoms.
“E” is incorrect because by definition, a concussion requires neurologic symptoms.

* *
Your patient opens his eyes on his own, follows commands, answers all orientation questions correctly, but appears unsteady when ambulating.
His Glasgow Coma Scale (GCS) is:
A) 5.
B) 10.
C) 14.
D) 15.
E) 20.

Answer And Discussion

The correct answer is “D.” 15

The GCS is a scale used to indicate the severity of neurologic dysfunction and is often applied to victims of head trauma. Remember, however, that it does not predict mortality or morbidity
but is only used as a descriptive scale of the patient’s current state. Only the maximum score of 15 is considered a normal GCS.
There are three components to the GCS,

1. Eye opening:

• Spontaneous = 4
• To speech = 3
• To pain = 2
• No response = 1

2. Verbal response:

• Alert and oriented = 5
• Disoriented conversation = 4
• Nonsensical speech = 3
• Moaning = 2
• No response = 1

3. Motor response: 

• Follows commands = 6
• Localizes pain = 5
• Withdraws from pain = 4
• Decorticate flexion = 3
• Decerebrate extension = 2
• No response = 1

Independent of other factors, an entirely normal GCS score of 15 indicates that:

A) The patient does not require a head CT scan.

B) There is essentially no possibility that this patient has an intracranial injury requiring surgical intervention.

C) There is little or no possibility that this patient has any focal intracranial bleed.

D) There is up to a 4% chance this patient will need neurosurgical intervention.

E) None of the above.

Answer And Discussion

The correct answer is “D.” There is up to a 4% chance this patient will need neurosurgical intervention.

In appropriately selected patients (e.g., those with a significant mechanism of injury), about 18% with a GCS of 15 will have some intracranial lesion, and up to 4% will eventually require neurosurgical intervention. These are generally patients who have a depressed skull fracture but a normal GCS. 

“A” is incorrect since a normal GCS in and of itself does not allow one to forgo head CT in patients

with a significant mechanism of injury. “B” and “C” are also incorrect for the reasons noted earlier.

Remember that the GCS is not linear; a GCS of 14 is bad. Patients with a GCS of 14 must have a CTscan— unless another factor in the clinical decision making dictates otherwise (e.g., dementia, the finding is preexisting).

In an adult patient with a significant head injury, which of the following is NOT an indication for a head CT scan?

A) Intoxication with drugs or alcohol.

B) Vomiting once or more.

C) Amnesia or memory deficit.

D) Age greater than 40.

E) Seizure.

Answer And Discussion: The correct answer is “D.” Age greater than 40.

Older patients are at greater risk of developing serious intracranial injuries, but the age of 60 years or greater is usually used as an indication. While there is no “upper limit of normal” for vomiting after head trauma, the best data available suggest that any vomiting after head trauma in an adult indicates the need for a head CT scan. 

* *

You are going to transfer this patient for neurosurgical intervention to drain the subdural hematoma. It is about a 4-hour drive by ambulance to the nearest facility that has a neurosurgeon.

Which of the following is indicated as prophylaxis against increased intracranial pressure in this patient?

A) Hyperventilation after intubation.

B) IV mannitol.

C) Keeping the head of the bed elevated at 30 degrees.

D) IV dexamethasone.

E) None of the above.

Answer And Discussion

The correct answer is “E.”  None of the above.

None of the above is indicated as prophylaxis for increased intracranial pressure.

“A” is incorrect for two reasons. First, this patient does not need to be intubated. Second, routine hyperventilation as prophylaxis for increased intracranial pressure is of no benefit. This has been

well studied. What happens is that hyperventilation does cause vasoconstriction reducing intracranial

blood flow and therefore intracranial pressure. However, hyperventilation also causes ischemia around the area of the injury and may worsen outcomes. 

“B” is incorrect because prophylactic mannitol, like prophylactic hyperventilation, confers no benefit. “C” is incorrect. Elevating the head of the bed not only reduce intracranial pressure but also reduces perfusion pressure and is therefore a wash; there is no discernible benefit. 

“D” is incorrect since steroids are not useful acutely in head trauma (vs. spinal cord trauma). However, steroids are useful in cerebral edema secondary to tumor.