Unresponsive man on the street

[JNUS]

CLINICAL BACKGROUND

An unidentified 35-year-old man is found unresponsive on the street. Bystanders call for help. Responding prehospital personnel administer 2 mg of naloxone intravenously, but this has no effect. Given his unresponsiveness, the patient is intubated orotracheally in the field to protect his airway and is brought to the emergency department (ED). On arrival, the patient is agitated and is pulling at the endotracheal tube. He is sedated with benzodiazepine to prevent further injury and to prepare for multistep evaluation. The patient’s medical history and the events leading to his presentation are unknown.

On physical examination, the patient has a blood pressure of 120/85 mm Hg and a heart rate of 92 bpm. His rectal temperature is 99.2°F (37.3°C). With the assistance of a ventilator, his respiratory rate is 12 breaths/min. A bleeding scalp laceration approximately 6 cm long is observed over the occipital region. The patient's pupils are 2 mm and symmetric with sluggish reflexes. The corneal reflex is intact. He does not open his eyes spontaneously or on command, though the patient is periodically and spontaneously moving all 4 extremities. His physical findings are otherwise unremarkable, with no other signs of injury.

Laboratory investigations demonstrate a blood alcohol level of 405 mg/dL. The patient's complete blood count (CBC), electrolyte panel, liver function, and coagulation profile are within normal limits. No other drugs of abuse, such as opiates, are detected. A nonenhanced computed tomography (CT) scan of the patient’s head reveals a 28-mm acute collection of blood extending from the frontal lobe to the temporal lobe, with 10-12 mm of midline shift and uncal herniation.

What is the diagnosis, and what intervention is indicated given the patient's alcohol intoxication?


HINT
The intervention portion is effective and brief, and it involves a negotiation and an interview.

[rajupangeni]

looks like an epidural haematoma junus, probably resulting from a fall due to alcohol intoxication.. lenticular shape with inward convexity, sharp margins, acute (hyperdense).. and scalp edema over the occipital region as well.. doesnt seem to be having features of raised ICP and any localizing pupillary abnormality (is it usual in uncal herniation?)
i'd go for burrhole and immediate measures to control further rise in ICP.
epidurals usually are seen in temporoparietal region and usually are associated with overlying skull fracture right? a frontotemporal haematoma and laceration on occiput.. something must b wrong!
waiting for some other views.

[hydatidcyst]

This seems to be a case of Epidural Hematoma.

Evacuation of the collection by burr hole should be the primary objective after quick resuscitation of the patient. As the patient is intoxicated it is wise to try this under local anaesthesia.

Ventilation must be continued until the patient is able to breathe on his own. Mannitol is infused to reduce cerebral edema and lower intracranial pressure. Anticonvulsants are given to reduce post-traumatic seizures. Steroids are usually given to decrease inflammation by suppressing migration of leukocytes and to reverse increased capillary permeability, although some texts say they have no role.

Patient is nursed in head up position with the limbs restrained.

[Soul]

CT scan shows biconvex lenticular lesion which suggests Epidural hematoma. Subdural hematomas are crescent shaped. H/O fall also suggests epidural one coz subdural is usually caused by severe acceleration-deceleration trauma, or
shaking injury.

[Soul]

JNUS what is the answer?

[Walrus]

Originally Posted by rajupangeni

epidurals usually are seen in temporoparietal region and usually are associated with overlying skull fracture right? a frontotemporal haematoma and laceration on occiput.. something must b wrong!
waiting for some other views.

This may be a contre-coup injury.

[rajupangeni]

contrecoup injury is different walrus.. coup-contrecoup injuries are brain contusions that occur both at the site of the impact and on exactly the opposite side of it.. so injuries outside the brain parenchyma cant be coup or contrecoup.. i would expect a contre coup injury over the left frontal region with a direct impact over the right occiput.

[Walrus]

Originally Posted by rajupangeni

contrecoup injury is different walrus.. coup-contrecoup injuries are brain contusions that occur both at the site of the impact and on exactly the opposite side of it.. so injuries outside the brain parenchyma cant be coup or contrecoup.. i would expect a contre coup injury over the left frontal region with a direct impact over the right occiput.

Thank U Rajupangeni for your reply.

You are right that coup-contrecoup are contusions not hematomas but rarely they can be hematoma.

The explanation is that the impact on occipital region causes a negative pressure in right frontal fossa detaching the dura. Apparently, dura can be easily detached from the lateral frontal regions. So, that can give a hematoma.

But this is a rare phenomenon and only handful of cases have been reported.

I am just mentioning this for discussion though this may not be the explanation of the given case. But, the given scenario may be explained by this.

Alcohol >> falls down or fight >> impact on occipital region >> Contrecoup EDH

** Everyone agrees with the management portion but JNUS also mentions something about 'negotiation and interview' - so we have not quite touched that part. The patient is comatosed so - negotation and interview????

Ref
Tetsuryu MITSUYAMA, Mitsunobu IDE and Hirotsune KAWAMURA; “Acute Epidural Hematoma Caused by Contrecoup Head Injury”, Neurologia medico-chirurgica, Vol. 44, pp.584-586 (2004) .

[Soul]

ketaketi sanga case discuss garnu bhanya wastage of time rahechha

[rajupangeni]

great comment soul!
and walrus, u r right.. but in that case too, coup injury was on the left parietal region and contrecoup injury over the right frontal.. on the opposite side.. (not on the same side..) anyway i think u might b thinking on the right way.. something has to be wrong.. the frontal EDHs donot usually cause pupillary abnormalities and rapid deterioration.. that cud explain the clinical scenario (uncal herniation still doesnt fit).. may be he has suffered a double blow on his head.. is it the interview part for which jnus is referring to? just a discussion