A 24-year-old man is carried into the emergency department by friends after a fight in the street. During the fight, the patient was struck in the head with a knife, which became firmly implanted in his skull. His blood pressure is 106/72 mm Hg, pulse is 118/min, and respirations are 14/min. Pulse oximetry shows 93% on room air. His Glasgow Coma Scale score is 8. He opens his eyes to pain, and his speech is incomprehensible. Compressing the fingernail bed causes him to withdraw his hand. The estimated length of the knife is 14 cm, 3 cm of which have penetrated his skull. There is no other evidence of injury on his body. Which of the following is the most important next step in management of this patient?

Question

A 24-year-old man is carried into the emergency department by friends after a fight in the street.  During the fight, the patient was struck in the head with a knife, which became firmly implanted in his skull.  His blood pressure is 106/72 mm Hg, pulse is 118/min, and respirations are 14/min.  Pulse oximetry shows 93% on room air.  His Glasgow Coma Scale score is 8.  He opens his eyes to pain, and his speech is incomprehensible.  Compressing the fingernail bed causes him to withdraw his hand.  The estimated length of the knife is 14 cm, 3 cm of which have penetrated his skull.  There is no other evidence of injury on his body.  Which of the following is the most important next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bf53_71f3_8f63_450cbc563d30_MD0005_00 This patient is brought to the emergency department with a penetrating injury to his skull. As is true for any trauma, maintenance of an adequate airway and hemodynamic stability are the first steps in acute management. The Glasgow Coma Scale (GCS) score is useful in assessing level of consciousness and depth of injury. It consists of 3 parameters, scored against a standard scale: best eye (E) response (maximum of 4 points); best verbal (V) response (maximum of 5 points); and best motor (M) response (maximum of 6 points). GCS scores range from 3-15. Intubation is recommended for a GCS score <8. This patient opens his eyes to pain only. He makes incomprehensible sounds and withdraws his hand in response to painful stimuli. His GCS score is E2 + V2 + M4 = 8. His respiratory rate and oxygen saturation level suggest that he may be becoming hypopneic and hypoxemic. He should be intubated.(Choice B) Local wound management is not an emergency and can be addressed at a later stage. (Choice C) Removal of the knife may lead to an increase in bleeding due to opening of the dural venous sinuses. This should be attempted in the operating room. (Choice D) It is important to ensure the patient's hemodynamic stability and complete a full initial evaluation before any further radiographic imaging. Educational objective: Maintenance of an adequate airway and hemodynamic stability is the most important step in management of a trauma patient. Intubation is recommended for a Glasgow Coma Scale score <8. References: Management of severe head injury: new document provides guidelines. Brain Trauma Foundation. (http://www.ncbi.nlm.nih.gov/pubmed/9283374) Pre-hospital and initial management of head injury patients: an update. (http://www.ncbi.nlm.nih.gov/pubmed/24665251)

A 24-Year-Old Man Is Carried into the Emergency Department by Friends