“4 cases, 4 head injuries…” Case Conclusion September 6, 2012

Posted by Andy Jagoda, MD in: Neurologic, Radiology, Trauma , add a comment

Your 16 year-old soccer champ had no history of loss of consciousness, and while in the ED, his symptoms resolved completely within 2 hours. Using the CDC guidelines, you determined that a CT was not indicated. You discussed this with his parents, and he was discharged home symptom-free 6 hours after his injury. You instructed him and his parents about the importance of physical and cognitive rest (based on the Zurich Guidelines) until cleared by his primary care provider.

The 38-year-old woman in the low-speed motor vehicle crash had a loss of consciousness but no symptoms or risk factors. Based on the CDC guidelines, you do not think a CT is indicated. You discussed with her the very low likelihood of a clinically important ICI, and she was discharged with head injury precautions and information about postconcussive syndrome.

The history on the 2-month old baby was inconsistent, so you suspected abuse. She had a small hematoma in the left parietal region, and you ordered a CT, which revealed a small subdural. Child Protective Services was called, and the patient was admitted to the PICU.

Your drinking buddy sobered up quickly, but you convinced him to wait for the CT you ordered based on the following CDC criteria: presumed loss of consciousness, intoxication, and physical evidence of trauma above the clavicles. His CT showed atrophy but was otherwise normal. You provided him with follow-up and clear discharge instructions, which he promptly threw in the trash on the way out. Another night in the ED…

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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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