HISTORY. If the patient has been in an MVC, determine the speed and type of the vehicle, the patient's position in the vehicle, whether the patient was restrained, and whether the patient was thrown from the vehicle on impact. If the patient was injured in a motorcycle crash, determine if the patient was wearing a helmet. Determine if the patient experienced momentary loss of reflexes, momentary arrest of respiration, loss of consciousness, and the length of time the patient was unconscious. Determine if the patient has been experiencing excessive sweating (hyperhidrosis) or hypertension since the injury.

PHYSICAL EXAMINATION. The initial evaluation is centered on assessing the airway, breathing, circulation, and disability (neurological status). Exposure (undressing the patient completely) is incorporated as part of the primary survey. The secondary survey, a head-to-toe assessment, including vital signs, is then completed. Note a very high fever, hyperhidrosis, or hypertension. Observe posturing for flexion or extension.

The initial and ongoing neurological assessment includes monitoring of the vital signs, assessment of the level of consciousness, examination of pupil size and level of reactivity, and assessment of the Glasgow Coma Scale, which evaluates eye opening, best verbal response, and best motor response. Clinical findings may include a rapidly changing level of consciousness from confusion to coma, ipsilateral pupil dilation, hemiparesis, and abnormal posturing that includes flexion and extension. A neurological assessment is repeated at least hourly during the first 24 hours after the injury.

Examine the patient for signs of a basilar skull fracture: periorbital ecchymosis (raccoon's eyes), subscleral hemorrhage, retroauricular ecchymosis (Battle's sign), hemotympanum (blood behind the eardrum), and leakage of cerebrospinal fluid from ears (otorrhea) or nose (rhinorrhea). Gently palpate the entire scalp and facial bones, including the mandible and maxilla, for bony deformities or step-offs. Examine the oral pharynx for lacerations, and check for any loose or fractured teeth.

PSYCHOSOCIAL. DAI may alter an individual's ability to cope effectively. It may lead to significant cognitive and behavioral disabilities. Although it is not possible to assess the comatose patient's coping strategies, it is important to assist the family or significant others.

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