lower extremities. (c)Anterior cord syndrome results in variable degrees of
motor paralysis and absent pain sensation below the level of the lesion. Its
hallmark is preservation of vibratory sensation and proprioception because
of an intact dorsal column. (e)Cauda equina injury causes peripheral
nerve injury rather than direct spinal cord damage. Its presentation may
include variable motor and sensory loss in the lower extremities, sciatica,
bowel and bladder dysfunction, and saddle anesthesia.
137.The answer is a.(Tintinalli, pp 1557-1569.)Head injury severity is
assessed on the mechanism of injury and on the initial neurologic exami-
nation. Although the GCS is currently used in multiple settings, it was ini-
tially developed for the clinical evaluation of hemodynamically stable,
adequately oxygenated trauma patients with isolated head trauma. A score
of 14 to 15 is associated with minor head injury, 9 to 13 indicates moderate,
and8 or lessis associated with severe head injury. His GCS score is 8
(2 pointsfor eye opening to pain, 2 points for mumbling speech, 4 points
for withdrawing from pain). He is classified with a severe head injury. The
overall mortality of severe head injury is almost 40%. It is recommended to
intubatepatients with a GCS score of 8 or lessfor airway protection.
These patients are at risk for increased ICP and herniation, which can lead
to rapid respiratory decline. All patients with severe traumatic brain injury
require an emergent CT scan and should be admitted to the intensive care
unit in a hospital with neurosurgical capabilities.
(b)Repairing his laceration is not a priority and can take place after
diagnosing and stabilizing injuries that are more serious. If there is an
active scalp bleed, staples can be rapidly placed to limit bleeding until
definitive repair can take place. (c)Mannitol is an osmotic agent that is
used to reduce ICP. It is administered if there are signs of impending or
actual herniation (eg, fixed and dilated pupil). (d)Bilateral ED trephination
(burr holes) is rarely, if ever, performed and is considered if definitive neu-
rosurgical care is not available. (e)Although this individual may require
neurosurgical intervention (eg, if there is any evidence of intracranial hem-
orrhage or declining neurologic status, indicating increased ICP), priority is
given to his airway.
138.The answer is c.(Rosen, p 384.)Flail chestresults when three or
more adjacent ribs are fractured at two points, allowing a freely moving
segment of the chest wall to move in a paradoxical motion. It is one of the
most commonly overlooked injuries resulting from blunt chest trauma.
156 Emergency Medicine