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Emerg Med Serv. 2001 Jul;30(7):102.

The injured coach.


The patient in this case was diagnosed as having an epidural hematoma (shown in x-ray at right). This results from hemorrhage between the dura mater and the skull. The hemorrhage may result from a traumatic insult to the side of the head, which can fracture the temporal bone and lacerate the middle meningeal artery. Since the hemorrhage is arterial in nature, the patient may deteriorate quickly. These patients may present with what is referred to as a "lucid interval." The patient typically has a significant blow to the head that results in a short period of unconsciousness. They then regain consciousness at a time that frequently coincides with the arrival of EMS. Once conscious, they are in a period known as the lucid interval. They will still have a headache, but may otherwise be acting normally and show no other physical findings on examination. Many such patients refuse treatment and transport. [table: see text] Inside the skull, however, the problem will grow. Broken arterial vessels are bleeding, causing an expanding hematoma. The patient typically will soon complain of a severe headache along with other associated complaints, such as nausea/vomiting, then will lose consciousness again and/or have a seizure. Initial physical findings may include contralateral weakness and a decreased Glasgow Coma score. As the hematoma expands, cerebral herniation may occur, compressing the third cranial nerve, which presents as a "blown pupil." EMS providers should have a high suspicion of injuries that affect the side of the head and the base of the skull. It is important to not only assess such injuries, but also the mechanism of injury, and to know the complications or later presentation that can arise from such injuries. Given that this patient was alert, oriented, not obviously intoxicated, and accompanied by his wife, the providers in this case would have had no choice but to abide by a refusal of treatment and transport. However, that could lead to serious complications, such as ongoing minor neurological deficits, later on. If this is the case, contacting medical control should be the priority.

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