A 27-year-old man is brought to the emergency department by his roommate due to headache and lethargy. The patient is unable to provide any history, but his roommate says the patient returned to the apartment an hour ago after having a few drinks at a bar where he was also involved in an altercation. Since then, he has had worsening headache, vomited twice, and became progressively lethargic. The patient drinks 2-3 beers daily and does not use tobacco, but occasionally smokes marijuana. Blood pressure is 146/88 mm Hg and pulse is 92/min. On physical examination, he is somnolent and his breath smells of alcohol. A noncontrast CT scan of the head is shown in the exhibit. Which of the following is the best next step in management of this patient?

Question

A 27-year-old man is brought to the emergency department by his roommate due to headache and lethargy.  The patient is unable to provide any history, but his roommate says the patient returned to the apartment an hour ago after having a few drinks at a bar where he was also involved in an altercation.  Since then, he has had worsening headache, vomited twice, and became progressively lethargic.  The patient drinks 2-3 beers daily and does not use tobacco, but occasionally smokes marijuana.  Blood pressure is 146/88 mm Hg and pulse is 92/min.  On physical examination, he is somnolent and his breath smells of alcohol.  A noncontrast CT scan of the head is shown in the exhibit.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d53b_1a8b_bc81_fda83bc002ca_MD0003_00 This patient with headache, vomiting, and progressive lethargy has a biconvex hyperdensity on CT scan of the head consistent with an epidural hematoma. An epidural hematoma is most common in young adults and occurs as a result of traumatic head injury (eg, assault, as in this patient), typically following a blow to the skull with fracture of the sphenoid bone. This frequently leads to tearing of the middle meningeal artery, resulting in the buildup of blood between the dura mater and overlying skull. biconvex hyperdensity on CT scan of the head Patients may experience a brief loss of consciousness followed by a lucid interval. Hematoma expansion leads to signs of increased intracranial pressure (eg, headache, nausea/vomiting, altered mental status). CT scan of the head typically reveals a hyperdense biconvex lesion that does not cross suture lines. There may also be an associated midline shift due to mass effect. Symptomatic patients with focal deficits or signs of intracranial hypertension require emergent neurosurgical hematoma evacuation because treatment delay may lead to death secondary to brain herniation. (Choice A) Close observation and serial (every 6-8 hours) CT scans may be appropriate in patients with a small epidural hematoma without significant neurologic dysfunction. This patient is lethargic and requires urgent surgical intervention. (Choice C) Intravenous mannitol is an osmotic diuretic that can reduce brain volume in patients with elevated intracranial pressure; however, hematoma evacuation is the definitive therapy, and serial examinations without neurosurgical intervention would result in increased mortality. (Choice D) Prothrombin complex concentrate infusion, which contains 4 vitamin K-dependent clotting factors, is indicated for rapid reversal of anticoagulation in patients with intracranial hemorrhage. However, this patient is not anticoagulated. (Choice E) Vitamin B₁ (thiamine) infusion, followed by intravenous glucose, is used to treat Wernicke encephalopathy, which occurs in patients with chronic malnourishment (eg, alcohol abuse). Patients demonstrate ophthalmoplegia, encephalopathy, and ataxia, but not a biconvex hyperdensity on CT scan of the head. Educational objective: Epidural hematoma is most common in young adults and occurs as a result of traumatic head injury, which leads to tearing of the middle meningeal artery and bleeding between the dura mater and skull. CT scan of the head typically reveals a hyperdense biconvex lesion that does not cross suture lines. Symptomatic patients require emergent neurosurgical hematoma evacuation. References: Extradural haematomas in children: a 10-year review. (http://www.ncbi.nlm.nih.gov/pubmed/19922272) Images in clinical medicine. Traumatic epidural hematoma. (http://www.ncbi.nlm.nih.gov/pubmed/19196678)

A 27-Year-Old Man Is Brought to the Emergency Department by His