4 cases, 4 head injuries…

It’s 8 PM and you are just getting into the groove of your first in a series of several night shifts. After picking up your fourth head injury chart, you think to yourself, “Good grief, are we having a sale on head injury tonight?” Your patients are:

  • A 16-year-old boy brought in by his parents after head-butting another player during a soccer game. He was confused for several minutes and now has a headache. His coach told his parents that he had a concussion and should go to the ER to be checked out before he can return to play.
  • A 38-year-old woman who was in a low-speed motor vehicle crash. She states that she “blacked out” for a few seconds but feels fine now.
  • A 2-month-old brought in by her parents with a bump on her head. They said the babysitter told them the baby rolled off the bed while she was changing her diaper.
  • A well-known (to you) alcoholic brought in by the police, intoxicated, with an abrasion on his forehead. He has no idea how he hit his head and is asking for something to eat.

These are 4 cases of what appear to be minor injuries, although you know there is the chance that any of the patients may be harboring a neurosurgical lesion and that all 4 are at risk for sequelae. In your mind, you systematically go through the high-return components of the physical exam of a head-injured patient, the indications for neuroimaging in the ED, and the information needed at discharge to prepare the patients and their families for what might lie ahead. The medical student working with you is very impressed with the complexity of managing these cases, which he thought were so straightforward.

How do you handle these cases?

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ow do you handle these cases?

Last Updated on January 26, 2023

8 thoughts on “4 cases, 4 head injuries…

  1. the priority here for the baby2month and the alcoholic patient these need good physical and neuroimaging evaluation and observation in the ER.
    The others due to low severty of the accedent,and age ,and medical history free and no anticoagulant using,and the condition after accident they only need for good physical examination and observation for 6 hour in the ER .IF NO other sympotms (sever headache or vomiting,loss of consousness,dizzines ,abnormal gait) appears in the ER can discharge them home and full instrucation to come back emergently if likes any of these symptoms(sever headache or vomiting,loss of consousness,dizzines ,abnormal gait) appears again at home.and close follow up by parents or caregiver.

  2. The first pt with concussion is confused and most likely has extradural hematoma.he needs a CT brain to exclude any hemorrhage. Or edema

    second pt has a history of loss of consciousness despite a low speed accident also needs neuro imaging with close monitoring might have itracerebral bleed or concussion

    third pt needs close monitoring, for irritability, crying a lot and agitation because there neuro. Symptoms

    fourth patient is fully conscious though has no memory of what happened needs a CT brain to exclude extradural homorrhage that could drop his gcs in no time. Close monitoring

  3. First case head injury c t head may be contusions
    subarachnoid bleed
    Second case concussion ii injury
    Third case scalp hematoma no need for ct head observe the child
    Fourth case go for c t head send blood sugar level

  4. 16yr old pt need to have head CT to r.o intracranial contution.
    The 38 yr old needs a CT scan of head as well
    The 2 mo old need CT scan too based on Head CT scan rule
    The last pt needs a CT scam as well.

  5. Do a CT scan. Admit the patients and keep them at
    least overnight for observation. Observe patient for vomiting, disorientation, increasing severity of headache. Monitor patient’s level of conciousnes, vital signs, papilledema.

  6. case 1: i would ct scan him if patient gcs < 15/15 2 hours after incident, or vomiting post trauma. either way he is not going to play even if he don't get ct scan…i would observe him for concussion in ed,,,might be up to 12 hours. or if patient or family not willing to be observed…CT scan him straight away.

    case 2: admit for observation for signs of ICB..at least up to 12 hours.if no signs discharge with head injury advice.

    case 3: screen for non accidental injury. get more details regarding mechanism of injury…height of fall etc. might not do ct scan yet…but might do skull xray, funduscopy. may proceed ct scan based other clinical finding.

    case 4: ct scan this alcoholic…..high risk for ICB

  7. Case 1: Assess & stabilise ABC awith C Spine immobilisation. Rest on trolley. Enough information to order a CT scan of head +/- Cx spine.
    Case 2: Unless there is clinical eveidence of s skull # – Observation only for 4 hrs. CT Head only if altered GCS <15 or other complications.
    1-2X vomits not significant.
    Case 3: More detailed history – very thorough exam and close observation. Consider ultrasound if available. If any significant concerns urgent CT head. Minimum 4 hrs neuro obs.
    Case 4: Nil by mouth. Immobilise Cx spine. BSL. Head to toe exam. CT Head. Thiamine IV. Standard biochemistry and FBE plus coagulation studies. Observe 4 hrs or until normal GCS. Diazepam if withdrawal scale above threshold. (local practice)

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