Welcome to this month’s What’s Your Diagnosis Challenge!
But before we begin, check to see if you got the previous case on Alkali Exposure: An Evidence-Based Approach to Diagnosis and Treatment correct.
Case Presentation: Management of Traumatic Intracranial Hemorrhage in the Emergency Department
A 24-year-old man with no past medical history presents by EMS following an unhelmeted all-terrain vehicle rollover accident…
- He has a temperature of 37.5°C, heart rate of 76 beats/min, blood pressure of 100/60 mm Hg, and respiratory rate of 17 breaths/min. His GCS score is 12 (E2V4M6).
- Computed tomography (CT) of the head, neck, chest, abdomen, and pelvis shows that he has bifrontal contusions, a skull fracture crossing midline, and a pelvic fracture.
- Two hours later, while consulting services are still pending recommendations, he becomes agitated and his GCS score has declined to 10 (E2V3M5). What treatments should you initiate and what additional imaging should you obtain?
Case Conclusion
Because this patient presented with symptoms suggesting high risk for developing critically elevated ICP (including his young age with likely ”full brain” at baseline) you gave him a 250 mL bolus of 3% hypertonic saline over 15 minutes. This was more appropriate than mannitol, given his low blood pressure. Because of his examination change and occipital skull fracture crossing midline, you ordered a repeat CT with CTV. Because of his agitation and declining examination, you intubated him prior to imaging, using neuroprotective strategies. Worsening intraparenchymal hemorrage was seen on CT, so you consulted neurosurgery and admitted him to the surgical ICU.
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Last Updated on April 7, 2025
