Kaplan USMLE Step 2: Next step for a patient with head trauma

If you’re preparing for the United States Medical Licensing Examination® (USMLE®) Step 2 exam, you might want to know which questions are most often missed by test-prep takers. Check out this example from Kaplan Medical, and read an expert explanation of the answer. Also check out all posts in this series.

A 34-year-old unconscious man is brought to the emergency department by paramedics after losing consciousness. Three hours ago, he was in a motor vehicle accident in which he was ejected from the car. On the scene, he denied loss of consciousness, was speaking and ambulating normally, and declined further medical care. His medical history is unremarkable, and he takes no medications. His pulse is 42/min, respirations are 12/min and irregular, and blood pressure is 160/96 mm Hg.

Neurologic examination shows that the patient is unresponsive to verbal or painful stimulation, and eye examination shows a fixed and dilated right pupil. The patient is subsequently intubated. Plain radiograph films of the lateral cervical spine show no acute abnormalities with visualization of C7–T1. A CT scan of his head is shown.

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

A. CT scan repeated in 8 hours

B. Emergent craniotomy

C. Hypertonic saline drip in the ICU

D. Hyperventilation to PCO₂ <25

E. IV steroids

F. Ventricular shunt placement

The correct answer is B.

All patients diagnosed with an acute symptomatic (i.e., unresponsive, bradycardia, bradypnea, and hypertension) epidural hematoma on non-contrast head CT following a traumatic head injury should be managed with emergency craniotomy to evacuate the hematoma and lower ICP. This procedure provides the best means of rapidly evacuating the hematoma and preventing the impending brain herniation.

Choice A. Observation with serial CT scans is the correct course of action for a neurologically and hemodynamically stable patient that is diagnosed with an acute epidural hematoma but showing no evidence of increased intracranial pressure (ICP). However, the patient in this vignette is not stable and requires emergent surgical management to evacuate the hematoma and rapidly lower elevated intracranial pressure.