A 15-year-old boy is brought to the emergency department one hour after sustaining an injury during football practice. He collided head-on into another player while wearing a mouthguard and helmet. Immediately after the collision he was confused but able to use appropriate words. He opened his eyes spontaneously and followed commands. There was no loss of consciousness. He also had a headache with dizziness and nausea. He is no longer confused upon arrival. He feels well. Vital signs are within normal limits. He is fully alert and oriented. His speech is organized and he is able to perform tasks demonstrating full attention, memory, and balance. Neurological examination shows no abnormalities. There is mild tenderness to palpation over the crown of his head but no signs of skin break or fracture. Which of the following is the most appropriate next step?

Observe for 6 hours in the ED and refrain from contact sports for one week

Discharge without activity restrictions

Discharge and refrain from all physical activity for one week

Administer prophylactic levetiracetam and observe for 24 hours

Administer prophylactic phenytoin and observe for 24 hours

A 60-year-old male is admitted to the ICU for severe hypertension complicated by a headache. The patient has a past medical history of insulin-controlled diabetes, hypertension, and hyperlipidemia. He smokes 2 packs of cigarettes per day. He states that he forgot to take his medications yesterday and started getting a headache about one hour ago. His vitals on admission are the following: blood pressure of 160/110 mmHg, pulse 95/min, temperature 98.6 deg F (37.2 deg C), and respirations 20/min. On exam, the patient has an audible abdominal bruit. After administration of antihypertensive medications, the patient has a blood pressure of 178/120 mmHg. The patient reports his headache has increased to a 10/10 pain level, that he has trouble seeing, and he can't move his extremities. After stabilizing the patient, what is the best next step to diagnose the patient's condition?

CT head without intravenous contrast

Doppler ultrasound of the carotids

CT head with intravenous contrast

MRI head without intravenous contrast

MRI head with intravenous contrast

A 3-month-old boy is brought to the emergency department by his mom for breathing difficulty after a recent fall. His parents say that he rolled off of the mattress and landed on the hard wood floor earlier today. After an extensive physical exam, he is found to have many purplish bruises and retinal hemorrhages. A non-contrast head CT scan shows a subdural hemorrhage. He was treated in the hospital with full recovery from his symptoms. Which of the following is the most important follow up plan?

Inform child protective services

Provide parents with anticipatory guidance

Referral to genetics for further testing

Reassurance that accidents are common

A 77-year-old man with a history of hypertension and a 46 pack-year smoking history presents to the emergency department from an extended care facility with acute onset of headache, nausea, vomiting, and neck pain which started 6 hours ago and has persisted since. He is alert, but his baseline level of consciousness is slightly diminished per the nursing home staff. His temperature is 99.0°F (37.2°C), blood pressure is 164/94 mmHg, pulse is 90/min, respirations are 16/min, and oxygen saturation is 98% on room air. The patient's neurological exam is unremarkable with cranial nerves II-XII grossly intact and with stable gait with a walker. He is immediately sent for a head CT which is normal. What is the most appropriate next step in management?

Ibuprofen, acetaminophen, metoclopramide, and diphenhydramine

A 47-year-old man is admitted to the emergency room after a fight in which he was hit in the head with a hammer. The witnesses say that the patient initially lost consciousness, but regained consciousness by the time emergency services arrived. On admission, the patient complained of a diffuse headache. He opened his eyes spontaneously, was verbally responsive, albeit confused, and was able to follow commands. He could not elevate his left hand and leg. He did not remember the events prior to the loss of consciousness and had difficulty remembering information, such as the names of nurses or doctors. His airway was not compromised. The vital signs are as follows: blood pressure, 180/100 mm Hg; heart rate, 59/min; respiratory rate, 12/min; temperature 37.0℃ (98.6℉); and SaO2, 96% on room air. The examination revealed bruising in the right frontotemporal region. The pupils are round, equal, and show a poor response to light. The neurologic examination shows hyperreflexia and decreased power in the left upper and lower limbs. There is questionable nuchal rigidity, but no Kernig and Brudzinski signs. The CT scan is shown in the image. Which of the following options is recommended for this patient?

Surgical evacuation of the clots

Administration of levetiracetam

Administration of methylprednisolone

A 32-year-old man is brought to the emergency department after a skiing accident. The patient had been skiing down the mountain when he collided with another skier who had stopped suddenly in front of him. He is alert but complaining of pain in his chest and abdomen. He has a past medical history of intravenous drug use and peptic ulcer disease. He is a current smoker. His temperature is 97.4°F (36.3°C), blood pressure is 77/53 mmHg, pulse is 127/min, and respirations are 13/min. He has a GCS of 15 and bilateral shallow breath sounds. His abdomen is soft and distended with bruising over the epigastrium. He is moving all four extremities and has scattered lacerations on his face. His skin is cool and delayed capillary refill is present. Two large-bore IVs are placed in his antecubital fossa, and he is given 2L of normal saline. His FAST exam reveals fluid in Morison's pouch. Following the 2L normal saline, his temperature is 97.5°F (36.4°C), blood pressure is 97/62 mmHg, pulse is 115/min, and respirations are 12/min. Which of the following is the best next step in management?

Upper gastrointestinal endoscopy

Head trauma management for USMLE Step 3: High-Yield Surgery Lessons

Initial Assessment - First Responders' Field Guide

Scene Safety & C-Spine: First priority. Immobilize neck immediately if suspected trauma.
Primary Survey (ABCDE):
- Airway: Secure airway, use jaw-thrust if C-spine injury suspected.
- Breathing: Assess respiratory rate, effort, and oxygen saturation.
- Circulation: Check pulse, blood pressure; control external hemorrhage.
- Disability: Glasgow Coma Scale (GCS). GCS < 8 → Intubate!
- Exposure/Environment: Undress patient, prevent hypothermia.

Airway Maneuvers: Head-Tilt/Chin-Lift vs. Jaw-Thrust

⭐ High-Yield: In head trauma, altered mental status is presumed to be from intracranial injury until proven otherwise. Always prioritize airway protection and cervical spine stabilization over other injuries initially.

Imaging Decisions - When to Scan the Can

Non-contrast head CT is the gold standard for evaluating acute traumatic brain injury (TBI).
Decision tools like the Canadian CT Head Rule (CCHR) guide imaging for minor head injury (GCS 13-15).

⭐ Patients on anticoagulants (e.g., warfarin) or with bleeding disorders often require a CT scan even with minor trauma, as their risk of intracranial hemorrhage is significantly higher.

ICP Management - Keeping a Lid On It

Goal: Maintain ICP < 20-25 mmHg & Cerebral Perfusion Pressure (CPP) > 60 mmHg.
Formula: $CPP = MAP - ICP$.
Avoid hypotension (SBP < 90 mmHg) & hypoxia (PaO2 < 60 mmHg).

Monro-Kellie doctrine: ICP vs. intracranial volume

⭐ Cushing's Triad (Late Finding): Sign of severely ↑ ICP & impending herniation. Consists of: Hypertension, Bradycardia, and Irregular Respirations.

Specific Injury Patterns - A Rogues' Gallery of Trauma

CT Comparison of Intracranial Hemorrhages

Epidural Hematoma (EDH):
- Vessel: Middle meningeal artery (arterial).
- CT: Biconvex (lens-shaped) bleed. Does not cross suture lines.
- Classic Sign: Lucid interval before neurologic decline.
Subdural Hematoma (SDH):
- Vessel: Bridging veins (venous).
- CT: Crescent-shaped bleed. Can cross suture lines.
- Risk Factors: Elderly, alcoholics (due to brain atrophy).
Diffuse Axonal Injury (DAI):
- Mechanism: High-energy acceleration-deceleration (shear forces).
- CT: May appear normal initially; classic finding is punctate hemorrhages at the grey-white matter junction.

⭐ A thunderclap "worst headache of life" suggests Subarachnoid Hemorrhage (SAH), often from a ruptured berry aneurysm. CT shows blood filling the cisterns and sulci.

High‑Yield Points - ⚡ Biggest Takeaways

A Glasgow Coma Scale (GCS) score < 8 is an absolute indication for intubation.

Watch for Cushing's triad (hypertension, bradycardia, irregular respirations) as a sign of impending herniation.

Epidural hematoma: arterial bleed, classic lucid interval, and a lentiform shape on non-contrast CT.

Subdural hematoma: venous bleed, crescent-shaped, common in elderly and alcoholic patients.

Primary goals: maintain ICP < 20 mmHg and Cerebral Perfusion Pressure (CPP) > 60 mmHg.

Always begin with ABCs and rigid cervical spine immobilization.

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