During transport after a head injury, a 16-year-old becomes disoriented and agitated. What should you suspect?

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Multiple Choice

During transport after a head injury, a 16-year-old becomes disoriented and agitated. What should you suspect?

Disorientation and agitation that develop during transport after a head injury point to a rapidly enlarging intracranial bleed from arterial origin, most classically an epidural hematoma. This pattern comes from rupture of the middle meningeal artery often linked to a temporal bone fracture. After the initial impact, a patient may momentarily seem okay or have a brief loss of consciousness, then enter a lucid interval followed by sudden deterioration as the hematoma grows. As it expands, pressure builds inside the skull, leading to confusion, agitation, headache, vomiting, and sometimes unequal or dilated pupils. This progression is more typical of an expanding epidural hematoma than the other injuries listed. Subarachnoid hemorrhage usually presents with a sudden, severe headache and meningismus rather than a clear lucid interval with rapid mental status change. A concussion involves transient cognitive symptoms after a milder head injury and doesn’t typically show rapid clinical deterioration from a mass effect. A cerebral contusion can cause confusion or focal deficits but doesn’t typically produce the lucid-interval–followed-by-rapid-decompensation pattern seen with an expanding epidural hematoma.

Disorientation and agitation that develop during transport after a head injury point to a rapidly enlarging intracranial bleed from arterial origin, most classically an epidural hematoma. This pattern comes from rupture of the middle meningeal artery often linked to a temporal bone fracture. After the initial impact, a patient may momentarily seem okay or have a brief loss of consciousness, then enter a lucid interval followed by sudden deterioration as the hematoma grows. As it expands, pressure builds inside the skull, leading to confusion, agitation, headache, vomiting, and sometimes unequal or dilated pupils. This progression is more typical of an expanding epidural hematoma than the other injuries listed.

Subarachnoid hemorrhage usually presents with a sudden, severe headache and meningismus rather than a clear lucid interval with rapid mental status change. A concussion involves transient cognitive symptoms after a milder head injury and doesn’t typically show rapid clinical deterioration from a mass effect. A cerebral contusion can cause confusion or focal deficits but doesn’t typically produce the lucid-interval–followed-by-rapid-decompensation pattern seen with an expanding epidural hematoma.

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