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INTRODUCTION

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This chapter focuses primarily on the nonmusculoskeletal elements of the head and neck as the cervical spine and TMJ issues are covered in Chapter 10. The clinician starting their assessment of a patient typically first determines causation. The assessment process then follows as to traumatic versus nontraumatic patient presentation.

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Traumatic

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When trauma is the cause, the clinician immediately determines the likelihood of intracranial injury. As there is an inverse relationship of neurological status and cranial injury, the Glasgow coma scale is often used as the screen. The scale is a 15-point maximal assessment with three processes of assessment: eyes, verbal, and motor. It was initially used as a serial assessment in brain-injured subjects and now has become the most commonly used screen.1 A score equal to or greater than 13 is usually associated with a minor injury while a score of less than 8 or 9 is severe. The moderate or in-between scores are more challenging to interpret and then to determine the best approach to imaging. The ACR Appropriateness Criteria for head trauma indicate that the “go to” modality is most often a CT scan without contrast.2 When a patient has had minor/moderate trauma and has a Glasgow score above 13, clinicians have established additional specific risk factors to consider including headache, vomiting, drug intoxication, older ages (>60), seizures, and suspected fractures.3,4 These then enable those who fall outside the norm to be addressed and provides the proper restraint in relation to ionizing radiation exposures yet enabling required diagnostics.

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The great strengths of CT imaging of the head and neck include sensitivity to allowing visualization of the majority of internal structures to be assessed, speed of scanning, post-imaging manipulation, and few absolute contraindications. As clinicians continue to reduce the amount of ionizing radiation required for informed decisions, the urgency and value in CT use in cases of the head and neck outweigh the concerns for radiation exposure in nearly all situations, but especially in emergent care situations. In those with moderate or high risk of intracranial injury, the CT scan allows assessment of bleeding, midline shift (a lesion pushing into/from a side of the brain, and overall tissue changes (Figure 5-1).

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Figure 5-1

Head CT demonstrating a left frontotemporoparietal acute subdural hematoma with mass effect and mild midline shift. Subdural hematomas do not respect suture lines and are typically crescent shaped. (Reproduced, with permission, from Hall J, Schmidt G, Kress J. The Surgical Patient: Principles of Critical Care. 4th ed. New York, NY: McGraw-Hill Education; 2015.)

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In those reaching an emergency department early with signs of a cerebrovascular accident (CVA), the immediate use of the CT scan enables early delineation of a hemorrhagic versus ischemic/thrombotic presentation and thus allowing proper use of tissue ...

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