Case of the Month
March 2004

70-year-old female — neurologic deficits

EMTs are called to the scene of a two-car MVA. A Hummer (a 2 1/2 ton truck) struck a Toyota Corolla driven by a 70-year-old woman on the driver's side with significant intrusion into the door. The Hummer's driver is out of his vehicle and uninjured, but the Toyota's driver is complaining of a headache and confusion and shows a lateral gaze to the left. There is a head laceration and bruise over her left ear.

The patient is quickly classified in the SICK category due to significant MOI and altered LOC. EMTs begin c-spine stabilization, initial airway management, supplemental O2. The patient is given a rapid trauma survey, quickly extricated and prepared for medic arrival. No other injuries are found except the isolated head injury. The crew prepares for change in the patient’s status (e.g., suction, BVM for respiratory assistance).

What do you believe could be going on with this patient?

Neurologic Deficit Related to Region of Injury
Observable findings following head trauma can indicate where the brain is injured. The following summary is from Dr. Will Longstreth, head of neurology at Harborview Medical Center.

Trauma often affects frontal and temporal lobes of brain leading to change in behavior ranging from agitation and disinhibition (belligerence, anger) on the one hand, to withdrawal and apathy on the other. These patients often repeat the same question or statement over and over.

Injuries further back in the frontal lobes lead to motor deficits opposite the injured area and often with gaze preference towards the injured side (ie., our 70-year-old patient above). For injuries in the dominant hemisphere, aphasia (impaired or absent speech) can be seen and, in the non-dominant hemisphere, neglect (patient shows no or little interest in you).

More posteriorly in the occipital region, vision problems dominate with either loss of vision on one side (hemianopsia) or both (cortical blindness).

Coup-contre-coup often results in brain damage on the side of the skull opposite the impact. Patients who fall down and strike the back of the head may suffer frontotemporal contusions. Alternatively, patients who fall forward on the face may suffer occipital contusions, although the face with all its crushable structures does a better job of absorbing the energy of impact compared with the back of the head.

View coup-contre-coup animation — Click View Digital Animations and then click Types of Brain Injury Coup-Countrecoup Play