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Head Trauma, Acute — History and Physical — Clinical Pathway: Emergency

Acute Head Trauma Clinical Pathway — Emergency Department

History and Physical

History and Symptoms

Mechanism of Injury
  • Time
  • Location
  • Details
Loss of Consciousness Duration
Post-traumatic Amnesia Duration
Post-traumatic Seizure
  • Characteristics
  • Duration
Headache
  • Intensity
  • Location
  • Time of onset
  • Analgesia use
Vomiting
  • Time of onset
  • Number of episodes
  • Time of last episode
Dizziness
  • Sensation of vertigo
  • Physical imbalance
  • Postural instability
Intoxication Alcohol, drugs
Pertinent Past History
  • Developmental abnormality
  • Seizure disorder
  • Coagulopathy
  • Ventricular shunt

Physical Examination

Identify Life-threatening Injury
  • ABC’s
  • Vital signs
  • Glasgow Coma Scale
Evaluation for Altered Mental Status
  • Agitation
  • Somnolence
  • Repetitive questioning
  • Slow response to verbal communication
Evaluation of Scalp for Trauma
  • Bulging fontanelle in infants
  • Signs of basilar skull fracture
    • Retroaricular bruising
    • Periorbital bruising
    • Hemotympanum
    • CSF otorrhea or rhinorrhea
  • Palpable skull fracture
  • Hematoma
    • Size
    • Location
    • Boggy vs. firm
Neurologic Exam
  • Cranial nerves
  • Motor
    • Sensory exam
    • DTR’s
  • Gait
Look for Other Injury Complete physical examination (secondary survey)

 

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