4 cases, 4 head injuries… August 23, 2012

Posted by Andy Jagoda, MD in: Neurologic, Radiology, Trauma , 8 comments

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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“Traumatic Pain Management…” Case Conclusion August 6, 2012

Posted by Andy Jagoda, MD in: Drugs & Emergency Procedures, General Emergency Medicine, Trauma , add a comment

After establishing hemodynamic stability with your motor vehicle collision patient, you considered the potential for masking serious injuries with analgesia but realized that appropriate pain control has not been shown to contribute to missing serious injuries in this context. After a dose of IV fentanyl, her heart rate normalized and her pain improved, but she still had tenderness with palpation of the left upper quadrant. A CT scan showed a grade II splenic laceration but no other emergent pathology. You consulted a trauma surgeon, who agreed with your plan for admission for observation and pain control.

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