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Case 310

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A 66 year-old male patient is admitted unconscious to a trauma center after falling from a 3 meter height. His primary examination reveals: patent airway, symetric thoracic expansibility, non-laborious breathing, normal breath sounds, 22 respiratory incursions per minute, hemodynamic stability, 8 points in the Glasgow Coma Scale (GCS), isocoric non-photoreactive pupils and right otorrhagia. A non-contrast-enhanced head computed tomography (CT) scan is urgently acquired.

Taking into account the clinical scenario and the CT head scan results, what are the next best steps in this patient’s management?

a) Orotracheal intubation and neurosurgery

25%

b) 12 to 15 L/min oxygen therapy delivered by a mask-reservoir device and neurosurgery

25%

c) Orotracheal intubation, 20% manitol and close monitoring in the next 24 hours

25%

d) Orotracheal intubation, agressive fluid resuscitation and close monitoring in the next 24 hours

25%
   

Image Analysis

 

Image 1: Non-contrast-enhanced head CT, axial section, level of the occipital horns of the lateral ventricles, brain window. Right extra-axial supratentorial laminar heterogeneous collection with blood density (subdural hematoma, in yellow) associated with adjacent hypodense material (hatched) compatible with non-coagulated blood or cerebrospinal fluid due to arachnoid laceration, leading to subfalcine herniation and contralateral midline shift (black arrow).  Ipsilateral temporooccipital cerebral hemorrhage with adjacent hypodense halo – edema (in blue). Small subdural hematoma in the left frontal region (green arrow). Small right occipital pneumoencephalus foci (red arrow). Right temporoparietooccipital subgaleal hematoma (in red).

 

 

Image 2: Non-contrast-enhanced head CT, coronal reconstruction, level of the frontal horns of the lateral ventricles, brain window. Right extra-axial supratentorial laminar heterogeneous collection with blood density (subdural hematoma, in yellow), leading to subfalcine herniation and contralateral midline shift of up to 18mm. Partially hyperdense material in right sphenoidal sinus corresponding to hemosinus (in green). Right temporoparietooccipital subgaleal hematoma (in red). Physiological calcifications in cerebral falx (yellow arrow).

 

 

Image 3: Non-contrast-enhanced head CT, coronal reconstruction, level of the mastoid parts of the temporal bones, bone window. Fractures in mastoid part of the right temporal bone (arrows) associated with opacification of mastoid air cells (in purple). Mastoid part of left temporal bone with no anormalities.

Highlights

– The primary goal of treatment in severe taumatic brain injury (TBI) is to avoid secondary brain damage through hemodynamic and ventilatory stability, adequate cerebral perfusion and intracranial hypertension avoidance;

– All severe TBI victims should have an urgent computed tomography (CT) head scan;

– Patients with a score less than or equal to 8 in the Glasgow Coma Scale need a definitive airway;

– Acute subdural hematomas are seen in CT head scans as spontaneously hyperdense, extra-axial crescentic collections across the hemispheric convexity;

– Subdural hematomas with a clot thickness greater than 10 mm, midline shift greater than 5 mm, intracranial pressure persistently above 20 mmHg or with a decrease of 2 or more points in the Glasgow Coma Scale from the time of injury to hospital admission should be surgically drained.

References

– American College of Surgeons’ Comittee on Trauma. Advanced Trauma Life Support®: Student Course Manual. 10th ed. Chicago: American College of Surgeons; 2018. 420 p.;

– Osborn AG, Salzman KL, Barkovich AJ, editors. Diagnóstico por Imagem: Cérebro. 2a ed. Rio de Janeiro: Guanabara Koogan; 2011. 1272 p.;

– Schreiber MA, Aoki N, Scott BG, Beck JR. Determinants of Mortality in Patients With Severe Blunt Head Injury. Arch Surg [Internet]. 2002 Mar [cited 2018 May 18];137(3):285-90. Available from: https://jamanetwork.com/journals/jamasurgery/fullarticle/212202 DOI 10.1001/archsurg.137.3.285;

– Hemphill III JC, Smith WS, Gress DR. Neurologic Critical Care, Including Hypoxic-Ischemic Encephalopathy, and Subarachnoid Hemorrhage. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, editors. Harrison’s Principles of Internal Medicine. 19th ed. New York: McGrawHill Education; 2015. p. 1777-87;

– Hemphill III JC. Management of acute severe traumatic brain injury. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014 [cited 2018 Apr 16]. Available from: https://www.uptodate.com/contents/management-of-acute-severe-traumatic-brain-injury?source=history_widget;

– Mcbride W. Subdural hematoma in adults: Prognosis and management. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2014 [cited 2018 Apr 17]. Available from: https://www.uptodate.com/contents/subdural-hematoma-in-adults-prognosis-and-management?source=history_widget.

Author

Lucas Bruno Rezende, 6th year medical student at UFMG

Mail: lucasbrunorezende[at]hotmail.com

Supervisors

Marcelo Magaldi Ribeiro de Oliveira, neurosurgeon and adjunct professor of the Department of Surgery of the Faculty of Medicine of the Federal University of Minas Gerais

Mail: mmagaldi[at]hotmail.com

Túlio Cezar S. Bernardino, substitute professor of the Department of Anatomy and Imaging of the Faculty of Medicine of the Federal University of Minas Gerais

Mail: ituliob[at]gmail.com

Reviewers

William Pereira Alves, Lucas Cantaruti, Elaine Iwayama, Gabriel Santos, Professor José Nelson Mendes Vieira and Professor Viviane Parisotto

Translated by

Lucas Bruno Rezende, 6th year medical student at UFMG

Test question

[Medical Residency 2017: Faculty of Medical Sciences of Unicamp – SP]

A 7 year-old male patient is brought unconscious and with spontaneous breathing to the Emergency Department by Emergency Medical Services after having been run over and thrown a distance of approximately 10 meters. Physical examination: HR = 140 bpm; RR = 33 ripm; capillary refill time = 3 seconds. Head: frontal contusion. Neurological examination: the patient emits incomprehensible sounds, localizes pain and doest not open his eyes in response to painful stimuli. The patient’s conscious state and the best next step in airway management are:

a) Glasgow Coma Scale = 8; orotracheal intubation

25%

b) Glasgow Coma Scale = 11; mask-reservoir device

25%

c) Glasgow Coma Scale = 9; nasal cannula with an oxygen flow of 5 L/min

25%

d) Glasgow Coma Scale = 6; laryngeal mask airway

25%

e)

25%
   

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