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I don't quite understand your idea of a full trauma evaluation. I
presume you mean  as if one is facing a fresh injury with full ATLS
protocol. No, I don't think you would need all of that because, on the
evaluation when the patient was completely lucid 12-18 hours prior, the
patient appeared to have an isolated blunt closed head injury.
 
The issue of cervical spine injury has to be considered with the
mechanism & the height of the fall. Many of us including myself do clear
C-spines on patients, especially the older ones who are completely lucid
& without any distracting painful injuries based on a careful stepwise
clinical examination [ i.e. no midline tenderness or pain; no neurologic
deficits and full "active" ROM without pain] It appears as if this
patient may have met these criteria on his initial presentation and his
C-spine was cleared clinically. There is data from retrospective studies
in adults supporting this approach. However, we don't have any
prospective data validating this approach. I believe there is a
multi-center trial in California currently in progress looking at this
issue. As you can imagine, given the rarity of cervical spine injuries,
to demonstrate that a clinical examination has sufficiently low false
negatives(or high NPV) , the sample size is going to be huge.
 
Your question about delayed presentation of cervical spine injuries is
something I have not heard. However a delayed presentation of
intracranial bleeding after a normal initial CT is well described
especially within 24 hours. [Deitch D et al. Subdural hematoma after
normal CT. Neurology. 1989; 39:985-987; Poon et al. Traumatic extradural
hematomas of delayed onset is not a rarity. Neurosurgery.
1992;30:681-686.]
 
These occurrences are rare. Hence, there is support in the pediatric
literature to discharge patients with a normal CT even if vomiting,
PROVIDED the parents are reliable, understand CHT instructions & have
the ability to follow up. {Davis et al Pediatrics 1995. Dahl Grove et
al; PEC April 1995}
 
I actually agree with the move to intubate & hyperventilate prior to
transport, in the face of AMS & a subdural on the CT. Always a safe
strategy. I also agree with the Mannitol in the face of the new finding
of unequal pupils because this could be pre-herniation from third nerve
compression at the level of the falx. It is a myth to think that
mannitol will increase bleeding by shrinking the hematoma. There is no
evidence to prove that. In fact, to the contrary, in laboratory animal
data mannitol actually improved MAP & CPP & improved regional ischemia
in the face of raised ICP from a mass lesion. The only time I would be
hesitant would be if the patient was in hemmorhagic shock from other
injuries.
 
Hope that helps
 
Jay Pershad
 
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