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Risk of Traumatic Injury

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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 (see Image 1).

What is the diagnosis, and what intervention is indicated given the patient's alcohol intoxication?
CASE DIAGNOSIS
HINT
The intervention portion is effective and brief, and it involves a negotiation and an interview.
Authors:
Sarah Guzofski, MD,
Resident in Psychiatry,
University of Massachusetts Medical School, Worcester, MA

Ruben Peralta, MD,
FACS, Professor of Surgery,
Anesthesia and Emergency Medicine,
Senior Medical Advisor,
Board of Directors,
Program Chief of Trauma, Emergency
and Critical Care,
Consulting Staff,
Professor Juan Bosch Trauma Hospital,
La Vega, Dominican Republic

eMedicine Editor:
Rick G. Kulkarni, MD,
Assistant Professor,
Yale School of Medicine,
Section of Emergency Medicine,
Department of Surgery,
Attending Physician,
Medical Director,
Department of Emergency Services,
Yale-New Haven Hospital, Conn
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