1. A 58-year-old woman is brought to the emergency department (ED)by emergency medical service (EMS) after slipping on a patch of ice while walking to
... [Show More] work and hitting her head on the cement pavement. Bystanders acknowledged that the patient was unconscious for approximately 1 minute.On arrival, her vital signs are: blood pressure (BP) 155/75 mm Hg, heart rate (HR) 89 beats per minute, respiratory rate (RR) 18 breaths per minute, and pulse oxygenation 98% on room air. She has a 5-cm laceration to the back of her head that is actively bleeding. You ask the patient what happened but she cannot remember. You inform her that she is in the hospital as a result of a fall. Over the next 10 minutes she asks you repeatedly what happened and where she is. You do not find any focal neurologic deficits.As you bring the patient to the CT scanner she vomits once. CT results show a normal brain scan. Which of the following is the most likely diagnosis?
a. Cerebral concussion
b. Diffuse axonal injury
c. Cerebral contusion
d. Posttraumatic epilepsy
e. Trauma-induced Alzheimer disease
Answer: The answer is a. The patient sustained a cerebral concussion. This is caused by a head injury leading to a brief loss of neurologic function. These individuals are often amnestic to the event and frequently ask the same questions over and over again (perseverations). Headache with or without vomiting is generally present; however, there are no focal neurologic findings on examination. Loss of consciousness result from impairment of the reticular activating system. Patients show rapid Clinical improvement. CT scan is normal.
Diffuse axonal injury (b) is caused by microscopic shearing of brain nerve fibers. Patients typically present unconscious and remain in a coma for a prolonged period of time. Although the CT scan does not show a mass lesion, patients have over a 33% mortality rate. The clinical features of a cerebral contusion (c) are similar to those of a concussion except neurologic dysfunction is more profound and prolonged and focal deficits may be present if contusions occur in the sensorimotor area. These injuries occur when the brain impacts the skull. The lesion is typically seen on CT scan.
Posttraumatic epilepsy (d) is associated with intracranial hematomas and depressed skull fractures. The seizures generally occur within the first week of the head injury. Some scientists believe that head trauma predisposes to Alzheimer disease (e); however, this would take years to develop.
2. You are notified by the EMS dispatcher that there is a multiple-car collision on the local highway with many injuries. He states that there are two people dead at the scene, one person is critically injured and hypotensive, andbthree people have significant injuries, but with stable vital signs. Which of the following is the leading cause of death and disability in trauma victims?
a. Abdominal injury
b. Thoracic injury
c. Back injury
d. Cervical injury
e. Head injury
Answer: The answer is e. Trauma is the leading cause of death between the ages of 1 and 44 years. Many of these injuries are treatable mainly because the patients are young and otherwise healthy. The primary role of the emergency physician is to assess, resuscitate, and stabilize the trauma patient by priority. There are three peak times for trauma deaths.The first, classified as immediate death, is the period with the greatest number of fatalities. This occurs within seconds to minutes of the injury and these patients generally die at the scene. The cause is most commonly because of massive head injury, followed by high cervical spine injury with spinal cord disruption, cardiac and great vessel rupture, and airway obstruction. The second peak period, classified as early death, occurs within minutes to a few hours of injury. This is the period called the “golden hour” where intervention is critical and significantly reduces the morbidity and mortality rate in these patients. Death in these patient is generally secondary to subdural and epidural hematomas. Other causes of death in this group include ruptured spleen, lacerated liver, hypovolemic shock, fracture of pelvis or multiple long bones, hemopneumothorax, tension pneumothorax, cardiac tamponade, and aortic dissection or rupture. The third peak period, classified as delayed death, occurs days to weeks following the initial injury. Death in these patients is usually a result of multisystem organ failure and sepsis. [Show Less]