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Motor collision… February 27, 2013

Posted by Andy Jagoda, MD in : Neurologic , trackback

It is 2 am on a relatively busy shift on a Saturday night in the ED. EMS arrives with a 27-year-old male involved in a high-speed motor vehicle collision. He was not wearing a seat belt, and he was found ejected from the vehicle. Upon EMS arrival on scene, the paramedics found him unresponsive, with a GCS score of 9 (E2, V3, M4). The patient had been alone in the car, and he did not have identifying information with him. His vital signs included: blood pressure of 110/80 mm Hg, heart rate of 126 beats per minute, shallow respiratory rate of 8 breaths per minute, and oxygen saturation of 96% on room air. The paramedics attempted an oral airway, but it was aborted, because the patient exhibited a gag reflex. Bilateral nasal trumpets were placed, and a nonrebreather facemask with 100% oxygen was administered. He had deformities to his right ankle and left forearm. He smelled of alcohol. The patient was transported on a backboard with a rigid cervical spine collar to maintain immobilization. As you evaluate him on arrival to the ED, his vitals are essentially unchanged; however, you note that his GCS score is now 7 (E2, V2, M3), as he flexes his right arm to painful stimulus. IV access is established, and as you prepare to endotracheally intubate him, you recognize that this patient’s survival and ultimate neurologic outcome may depend on your initial management.

What would you do next?

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Comments»

1. R Weinland - March 1, 2013

check his sugar, and give him narcan, if no help, then rapid sequence intubate him, lido to decrease ICP, panscan him, labs, foley if no contraindication, xray extremities, deal with findings of scan, tx early if no NS capacity.

2. Ajay - March 1, 2013

Pretreat with lidocaine

3. Kambiz masoumi - March 1, 2013

1-tracheal intubation with RSI methods with in line immobilization of cervical spine and then cervical collar fixation and spinal column immobilization. 2-Request for neurosurgery consultation as soon as possible. 3-request for Brain CT- scan as soon as possible.4-Pay Attention to raised ICP and try for lowering it by manitol and hyperventilation if needed .5-consider metabolic cause such as drugs and try to ruling out them.

4. iram shakir kiani - March 1, 2013

xrays and or mri cervical spine and iv glucose plus thiamine stat

5. S E Allgood - March 1, 2013

The decerebrate response on the right may indicate herniation because of a an expanding intracranial bleed, and the absence of a response on the left would be suspicious of the mass effect being on the right. While high cord involvement could contribute to these findings, I would look carefully at the pupillary response. If it were necessary to treat based only on the information you present, it would be wise to trephine the skull to release an expanding hematoma (burr hole two finger breadths infront of and above the right ear…)

6. RAJNISH JAISWAL - March 2, 2013

Patient has Traumatic Intracranial Hypertension with signs of Decortication. Intubation with Hyperventilation to reduce ICP.

7. Dr Fasika - March 2, 2013

Etoh + trauma with altered LOC, high risk of head injury – sudden deterioration may be due to an inecrease icp and possibly brain herniation. Secure airway with spinal precautions. HOB at 30 degrees, Mannitol, mild hyperventilation. Stat CT head and neurosurgical consult.

8. jasman - March 2, 2013

possible head injury,urgent trauma protocol ct scan.rsi intubation,splintage r ankle and l forearm,i/v line sample for cross match,cbc,u/e,se.injection mannitol,prednisilone.neurosurgery/ortho opinion.inj tt,voveron.vitals monitoring.

9. Eric Jacobson - March 3, 2013

Primary survey, quick pupillary exam
Intubation with neuroprotective agents: lidocaine, opioids, defasic dose of paralytic, then etomidate and succ. or rocuronium, etc
IV fluids, crystalloids to maintain blood pressure and brain perfusion
Continue secondary survey: cxr, fast scan, if negative, splint, treat, stabilize secondary injuries in order of acuity, but don’t delay head ct.
Emergent head non con head ct and review, if pos for intracranial bleed or edema, consult neurosurgery, then follow vitals and start hypertonic saline vs mannitol therapy to reduce IC edema/pressure.
If herniation imminent, hyperventilate, in extreme situation with e/o IC hematoma , may consider burr hole.
Continue trauma pan-ct scan since physical exam not possible
Consult trauma surgery, stabilize other injuries as indicated, support vitals with fluids, pressors, mannitol/hypertonic saline, ventilation, etc. prep for surgery if indicated.

10. Fernando Cardona steadysword - March 4, 2013

Hi Dr Jagoda, thx for your clinical challenge

On this patient, I start with adecuate intubation secuence with fentanyl + midazolam 3-4 minutes preintubation, + etomidate, and succinilcholine 1-2 minutes previous to intubation, the nasotraqueal intubation is not an option, so I think on oral intubation, caution on the cervical spine, and check for adecuated intubation; next, search for tension Neumotorax, open neumotorax, unstable thorax, cardiac tamponade, or thoracic vital vessel lession, if that is not the clinical case of the patient, I would continue a infusion of 500 cc de IV crystaloids, compression of the bleeding injuries, and orogastric drainage; the gsc is 9/15, but also check the pupils; and start the secondary examination, ask for a thorax simple plain, pelvis plain, TAC brain and cervical and search for a ICU. and search the surgeon and neurosurgeon

11. ashok khanna - March 4, 2013

r/o injury to aorta especially rupture needs CT scan of chest with contrast

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