What is the immediate evaluation and treatment for an 18-year-old patient involved in a rear-end car accident with potential head and spinal injuries?

Immediate Evaluation and Management for an 18-Year-Old in a Rear-End Car Accident

The 18-year-old patient involved in a rear-end collision requires immediate cervical spine stabilization, neurological assessment, and a non-contrast head CT scan to rule out traumatic brain injury, even without loss of consciousness.

Initial Assessment and Stabilization

Cervical Spine Precautions

• Maintain spinal motion restriction by manually stabilizing the head to minimize movement of head, neck, and spine 1
• Suspect spinal injury due to the mechanism (motor vehicle crash) even without symptoms 1, 2
• Apply NEXUS criteria to determine need for imaging:
  • Midline spinal tenderness
  • Focal neurologic deficit
  • Altered level of consciousness
  • Intoxication
  • Distracting injury 2

Neurological Assessment

• Evaluate Glasgow Coma Scale (GCS) - patient currently has GCS 15
• Assess for signs of mild traumatic brain injury (TBI):
  • Altered mental state (feeling dazed, disoriented)
  • Loss of memory of events before or after accident
  • Any period of loss of consciousness 1

Diagnostic Imaging

Head CT Indications

• Non-contrast head CT is indicated for patients with mild TBI who have:
  • Any period of loss of consciousness
  • Amnesia for the event
  • Alteration in mental state at time of accident 1
• Even without loss of consciousness, the mechanism of injury (rear-end collision) warrants consideration for head CT

Cervical Spine Imaging

• CT is preferred over plain radiographs due to higher sensitivity 2
• If all NEXUS criteria are negative, the cervical spine can be cleared clinically without imaging 2
• If any NEXUS criteria are positive, obtain a three-view cervical spine series (lateral, anteroposterior, and odontoid) 1

Treatment Decisions

Observation vs. Discharge

• If head CT and cervical spine imaging are normal, and patient has normal neurological examination, consider discharge with head injury instructions 1
• If any abnormalities are detected, admission for observation is warranted

Pain Management

• For soft tissue injuries, apply cold to decrease hemorrhage, edema, pain, and disability
• Use a plastic bag or damp cloth filled with ice and water mixture for 20 minutes at a time 1
• Place a barrier between the cold container and skin to prevent cold injury 1

Special Considerations

Delayed Complications

• Even with normal initial imaging, monitor for delayed symptoms:
  • Worsening headache
  • Repeated vomiting
  • Increasing confusion
  • New neurological deficits

Documentation for HPI

• Document mechanism: "18-year-old involved in a rear-end collision while stopped at a traffic light"
• Document symptoms: "Patient reports hitting head but denies loss of consciousness"
• Document neurological status: "Alert and oriented, GCS 15, no focal neurological deficits"
• Document cervical spine assessment: "Midline cervical spine tenderness present/absent"

Common Pitfalls to Avoid

1. Failing to immobilize the cervical spine - Even without symptoms, maintain spinal precautions until cleared 1, 3

2. Premature discharge - Patients with mechanism for potential TBI should be observed for development of delayed symptoms 1

3. Inadequate imaging - When indicated, obtain complete imaging series rather than limited views 1

4. Overlooking associated injuries - Patients with head trauma have increased risk of cervical spine injuries (approximately 2% risk after blunt trauma) 1, 4

5. Ignoring subtle neurological symptoms - Even minor symptoms like feeling dazed can indicate mild TBI requiring evaluation 1