Head and NeckCHAPTER 1

A 55-year-old male presents to a small rural emergency department (ED) after a fall. The patient was attempting to fish during a beer festival event by standing on a rock. The patient slipped on the rock and subsequently fell and struck his head. On his arrival to the ED, his Glasgow coma scale (GCS) is 13. His alcohol level is 200 mg/dL. His complete blood count (CBC) is within normal limits and urine toxicology screen is negative. The Patient's vitals are unremarkable so it is deemed safe to obtain computed tomography (CT) scan of the head. A noncontrast CT scan reveals a subdural hematoma. A neurosurgeon at a nearby hospital is contacted and the patient is immediately airlifted to the awaiting operating room for surgery.

Following Figures 1 and 2 represent the subdural hematoma and its treatment.

Subdural hematoma is the most common cause of intracranial mass lesion.^1,2 It is defined as a collection of blood on the surface of the brain which may be acute, subacute or chronic. The acute type is usually caused by a high-speed impact to the skull. Risk factors include chronic alcoholism, epilepsy, coagulopathy, arachnoid cysts, anticoagulant therapy, cardiovascular disease, thrombocytopenia and diabetes. The cause is secondary to the shearing forces of small surface or bridging blood vessels. Subdural hematoma has a distinctive appearance on CT compared to epidural hematoma as it may appear as a crescent-shaped mass (Table 1).

The risk of severe brain damage is much higher than with epidural hematoma and increased intracranial pressure (ICP) is correlated with a worse prognosis.

Remember the mnemonic: A B B B C, when reading the CT Head

In children, if the child falls forward there is less risk of hemorrhage. However, if the child falls backwards it is moderate risk. Moreover, if the child falls on the side it is considered severe risk (Figs 8A to C).

A 10-year-old school boy presents to the emergency department (ED) after being attacked by a gang. The boy reports that five individuals gathered around the boy and beat him with baseball bats. Upon initial presentation to the ED, the boy is neurologically intact with normal mentation and Glasgow coma scale (GCS) is 15. Initial evaluation includes unremarkable vital signs and some bruising throughout on examination. While finishing the remainder of the examination, the patient becomes stuporous and comatose. Repeat GCS has decreased to 7 and Pupils are now sluggish to react. Vitals are reassessed as temperature 37°C, (98.6°F) blood pressure 180/90 mm Hg, pulse rate 50 beats/minute, respiratory rate 12 breaths/minute and O₂ saturation level 93%. The patient is intubated and taken, immediately for computed tomography (CT) which reveals an epidural hematoma in the right temporal region. A neurosurgeon is called and the patient is taken immediately to the operation room for surgical evacuation of the bleed. What type of bleeding is this patient likely to have?

Epidural hematoma is represented with the following Figures 1 and 2.

Only 20% of patients have the classic lucid interval. Patients may have severe headache, vomiting or seizures. Signs of increased intracranial pressure include hypertension, bradycardia and bradypnea. The medical professional should look for signs of herniation which would include a triad of coma, fixed pupils and decerebrate posturing in conjunction with contralateral hemiplegia. It occurs most commonly in the temporoparietal region due to location of the meningeal artery.

Protect the airway by intubating; maintain blood pressure; elevate head of bed; consider optimized hyperventilation; Mannitol to reduce cerebral edema and phenytoin should be given for seizure prophylaxis. Early neurosurgical consult is an absolute requirement.

A study of nonoperative management of epidural hematomas and subdural hematomas is done to investigate whether it is safe in lesions measuring one centimeter or less, (http://www.ncbi.nlm.nih.gov/pubmed/17693838) shows that EDH or SDH <1 cm thick can be safely managed nonoperatively unless there is concomitant cerebral edema.

Early involvement of a neurosurgeon is the most important duty of the emergency room MD. Surgical intervention is necessary for larger to intermediate epidural hematoma. It needs continuous careful individualized clinical approach based on radiological parameters: like thickness; midline shift; mass effect; and EDH location. For example, one of the study where a thickness of EDH > 18 mm, a midline shift > 4 mm, and a moderate to severe mass effect and the fourth criteria as location fairly predicted the outcome of epidural hematoma.

A recent high-profile case of epidural hemorrhage occurred in 2009 when actress Natasha Richardson (Fig. 3) suffered a head injury while skiing. After the injury, Natasha experienced a lucid interval and dismissed the paramedics and ambulance assistance. She twice refused medical care, but three hours later she developed a headache and was taken to a local hospital. Despite the best efforts of physicians and transfer to two other hospitals, she died the following day. Autopsy revealed that she had suffered an epidural hematoma due to blunt impact to the head. This case has helped raise the public awareness of the dangers of head trauma and has provided a needed reminder that headache can be the first sign of a major pathology. During the lucid interval patients may be reluctant to agree to testing or hospitalization, emphasizing the importance of education on the dangers of epidural hematoma.

A 30-year-old male presents to the emergency room (ER) and mentions to have experienced the worst headache of his life. The patient was sitting down for dinner after work, when all of a sudden he had severe pain in his head. The pain has been persistent for the last hour despite taking over-the-counter pain medications at home. The patient does not have a history of headaches in the past. He has faced no other medical problems in the past. He recalls that one of his relatives died suddenly at a young age from a bleed in his brain. The patient has smoked about a pack of cigarettes a day for the last 15 years. Vitals are as follows; temperature 38.5°C, blood pressure 190/100 mm Hg, pulse rate 120 beats/minute, respiratory rate 25 breaths/minute and O₂ saturation level 93% on room air. On physical examination, patient's alertness is waxing and waning. Emergency computed tomography (CT) has revealed subarachnoid hemorrhage (SAH). Nimodipine is started to control blood pressure. The head of bed is elevated to decrease intracranial pressure (ICP). Emergent neurosurgical consultation is obtained for evacuation of the bleed.

By definition, SAH is bleeding into the subarachnoid space which is the space between the brain and the tissues that cover it.¹ Causes include: arteriovenous malformation, bleeding disorders, cerebral aneurysms, head injuries, idiopathic and use of blood thinners. SAH from injuries is more common in the elderly population. In younger individuals, the most common cause is motor vehicle accidents. Bleeding from aneurysmal rupture happens in about 40–50/100,000 people over the age of 30 years. Risk factors include aneurysm in other blood vessels, fibromuscular dysplasia and other connective tissue disorders, high blood pressure, history of polycystic kidney disease and smoking. Family history of aneurysms also increases your risk.²

A patient may present to the emergency department with a headache and may be treated as sinusitis, especially where there are residency-teaching programs. Unless we have a high index of suspicion for headaches, we may miss a subarachnoid hemorrhage, CNS tumors, etc. Diagnosis should 12not be done hastily specially when you suspect a subarachnoid bleed or a tumor and you treat them with antibiotics for sinusitis or NSAIDS for headaches, the results may turn fatal. If a physician is not thorough in testing for SAH and the outcome results in death there will be hefty medicolegal and ethical consequences!

A 40-year-old female presents to the trauma bay after a motor vehicle accident (MVA). She was an unrestrained passenger in an accident in which a driver ran a red light and struck the driver side of her car. The driver also lost consciousness but was taken to another hospital. Initial assessment includes an intact airway with cervical collar in place. Patient is breathing spontaneously with adequate saturations. No signs of obvious bleeding are present. Distal pulses are all palpable and within the normal limits. Ecchymosis is found to be present periorbitally and on the abdomen. Glasgow coma scale (GCS) is 7. Due to GCS score, the patient is intubated before being assessed further. The patient is unresponsive and no family member is present. Vital signs are as follows: temperature 36°C, blood pressure 90/60 mm Hg and pulse rate 125 beats/minute. The patient is now on the ventilator. Normal saline bolus is given. Intracranial and intra-abdominal bleeding is suspected. Patient is sent for further imaging of head, cervical spine, chest and abdomen. Basilar skull fracture, subarachnoid hemorrhage and intra-abdominal hemorrhage due to liver laceration are revealed. Surgical and neurosurgical consultations are obtained. Careful monitoring of vitals is continued before the patient is sent to the operation room (OR) for definitive management.

Traumatic brain injury (TBI)¹ is a dynamic injury process due to cerebral edema, an increase in intracranial pressure (ICP) and anoxia (Fig. 1). It is usually related to rapid deceleration as seen in a motor vehicle accident, diving accident or blunt trauma. Initially, bleeding may be present followed by secondary injury due to cerebral edema. These injuries may have permanent consequences. There are 1.4 million cases in the United States per year with 50,000 deaths. A total of 235,000 hospitalizations and 1.1 million treated in the emergency department (ED). Of those that present to the ED, 80% are discharged, 10% are mild, and 10% are serious.

Educate your patients and community at large by supporting government laws and policies to prevent motor vehicle crashes and other sport related injuries. Educational handouts like a take-home point from the doctor are always helpful. Always wear your seat belt when traveling in the car and wear your helmet when traveling by motorcycle! Wear protective gear while playing contact sports.

A 45-year-old African-American male lost control of his vehicle during a snowstorm. The vehicle flipped three times in a row before coming to rest in the ditch at the side of the road. The patient was extricated from his vehicle and transported to a nearby hospital. On arrival, the patient is immobilized and has a large scalp hematoma. All imaging findings, including cervical-spine (C-spine) X-ray, are interpreted as normal despite having a poorly visualized cervicothoracic junction (Figs 1 and 2). Based on negative studies and absence of pain, the nurse has removed the C-spine collar. After walking just down the hallway, the patient collapses. It is now found that the patient has experienced an anterior subluxation of the C-spine. Is this case approached correctly? How can we prevent spinal cord injury? What imaging is required to rule out C-spine injury during trauma?

Cervical spine is the most vulnerable to injury because of its high mobility and exposure. The cervical canal is wider in the upper part from the foramen magnum to the lowest part of C2. The majority of patients with injuries around C2 vertebra who survive are neurologically intact when they arrive to the hospital. One-third of patients who have upper cervical injuries die at the scene of the injury secondary to apnea caused by an injury at C1 vertebra which denervates the phrenic nerves.

Don't leave the patient on a hard surface, such as a backboard, for a long period of time. This may lead to formation of serious decubitus ulcers in patients with spinal cord injuries. The patient should be evaluated by the appropriate specialist and removed from the spine board as quickly as possible. Nobody should be left on the spine board for more than 2 hours. If a patient has to be immobilized for more than 2 hours, they must be logrolled every 2 hours, maintaining the integrity of the skin and spine.

A 40-year-old female presents to the emergency department (ED) with a headache persisting over the past several weeks. The patient has never had headaches like this before. The headache is unilateral on the right side. The patient is thought to have migraine headaches and is discharged home with oral analgesics for pain and antiemetics to control her nausea. One week later, emergency medical service (EMS) is called again because the patient is found to be unresponsive. Narcan is given which results in some mild improvement. The patient is thought to have been overusing hydrocodone and is sent home with further instructions for treating her migraine headache. The patient is dissatisfied with this diagnosis because she has never had migraine headaches before in her life. Subsequently, she decides to go to a different hospital. This time, computed tomography (CT) head is ordered and the patient is found to have a large right frontal tumor. Before surgery can be scheduled, the patient passes away.

This sad case can be taken as a lesson to look for red flag signs in headaches. Causes of headaches can range from simple tension headache, to subarachnoid hemorrhage, to malignancy and therefore must be taken seriously. In this case, the patient warranted a CT scan due to the new onset of the headaches. It would also be important to assess her neurologic status, because a tumor of this size may have caused neurologic abnormalities. Neurologic assessment may have been missed because the patient was incorrectly assessed as having abused her narcotic medication.

This case also stresses the need for close monitoring and follow-up to ensure that patients do improve once they leave the ED.

In HIV patients, primary central nervous system (CNS) lymphoma is a frequent cause of neoplasm. For metastatic neoplasms, lung is the most common cause of metastasis.

Keep in mind, every headache can be a big headache.

A 12-year-old male presents to the emergency department (ED) after being knocked out during a football game (Fig. 1). The patient was running with the football when he was tackled, the opposing player put his helmet into the patient's helmet causing his head to fly back violently and he lost consciousness for a few seconds. The patient is experiencing some nausea and has had several episodes of vomiting. He has never had a concussion before, other than the brief episode of loss of consciousness, he denies amnesia of the event. On examination, vitals are temperature 36.8°C, blood pressure 108/70 mm Hg, pulse rate 65 beats/minute, respiratory rate 15 breaths/minute, and O₂ saturation level 100% on room air. The patient is found to be neurologically intact on cranial nerve, strength, sensation and reflex examination. He is given Zofran and Tylenol and is then observed in the ED. Because the patient begins to experience worsening nausea a CT head is done which is found to be unremarkable. What is the next best step in management? What needs to be done before the patient can return to play?

A concussion is a complex process affecting brain function induced by a traumatic biochemical force. Concussions predominantly occur between the ages of 12 years and 24 years, and more commonly in males. Risk factors include contact sports (especially football) and recent concussion (Figs 2A to C). Prevention should include educating coaches and athletes, rule enforcement and possibly rule changes. Current protective headgear has not been shown to prevent concussions however they are still mandatory. Improvement of such devices are being researched and developed.

The physician should assess for airway, breathing and circulation (ABC), evidence of trauma, neurologic examination and cervical spine injury. Sideline assessment of concussion and serial cognitive evaluations may be used to determine if patient has returned to baseline. Patient must be assessed by a primary care doctor, not an emergency medicine physician in order to return to play.