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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 76-year-old man is evaluated in the emergency department for a 3-day history of severe pain and spasms in his neck and lower back, mild dizziness when standing or walking, and some mental cloudiness. He attributes these symptoms to a low-velocity automobile collision he was involved in 4 days ago. He has no focal weakness or numbness and no alterations in his vision or speech. The patient has a history of atrial fibrillation treated with digoxin, warfarin, and metoprolol.

On physical examination, blood pressure is 142/80 mm Hg and pulse rate is 74/min and irregular. Paraspinal muscle spasms in the cervical and lumbosacral areas are present. Examination of the extremities shows normal reflexes and sensory and motor findings. A mildly ataxic gait is noted.

Q.

Which of the following is the most appropriate initial step in management?

This patient should have a CT scan of the head. Subdural hematoma is a key consideration in a patient with recent head or neck trauma and cognitive symptoms. Whereas epidural hematoma development generally requires direct trauma to the skull, a subdural hematoma may occur after relatively minor injuries to the cervical spine or head that create concussive forces within the cranium. Unlike epidural hematoma, which presents rapidly because of laceration of the middle meningeal artery, a subdural hematoma involves disruption of bridging veins between the brain parenchyma and dura and may develop slowly over days to weeks. Older populations are particularly prone to subdural hematomas, and the use of anticoagulant therapy, which is also common in this group, is another risk factor for intracranial hemorrhage. A CT scan of the head without contrast is generally diagnostic for acute subdural hematomas and is the imaging modality of choice for acute head trauma.

After a diagnosis of subdural hematoma is confirmed, a neurosurgical consultation is indicated. Patient presentation, examination abnormalities, and CT findings are all considerations weighed by the neurosurgeon in determining the necessity and timing of surgical evacuation.

This patient reports mental cloudiness and has ataxia on examination. These intracranial concerns override the back and neck pain and spasms he is experiencing. The muscle relaxant cyclobenzaprine would address only the symptom of paraspinal spasm and may worsen the cognitive and gait dysfunction in this older patient.

Similarly, meclizine may be effective in the management of the dizziness of vestibular origin that sometimes follows whiplash injuries, but the physical examination findings in this patient should provoke a search for alternative explanations for his dizziness and ataxia.

Physical therapy rehabilitation is premature before neuroimaging has been completed in a patient with this history and these examination findings.

Key Point

  • A CT scan of the head without contrast is generally diagnostic for acute subdural hematomas and is the imaging modality of choice for acute head trauma.
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