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- Head trauma
- accidental falls
- prehospital care
- doctors in PHC
- major incident planning
- major incidents
- intensive care
A 62-year-old electrician presented to the emergency department following an unwitnessed fall from a ladder resulting in loss of consciousness and epistaxis. He had two episodes of protracted vomiting prior to the arrival of the ambulance. At the scene, epistaxis control was attempted by pinching the nose, although he was still dry retching at the time. His initial Glasgow Coma Scale was 13, which increased to 15 en route. In the emergency department his Glasgow Coma Scale quickly fell to 10 and his pupils became unequal and unreactive. The initial CT scan revealed significant brain injury and extensive pneumocephaly (figure 1).
An emergency left-sided craniectomy and evacuation of a present subdural haemorrhage was performed. However, subsequent imaging revealed a non-survivable brain injury and the patient died 2 weeks later.
It was considered that the pneumocephalus may have been worsened by the inadvertent Valsalva manoeuvre resulting from vomiting and dry retching against a pinched nose. This in turn may have contributed to the patient's precipitous deterioration in the emergency department.
Pneumocephalus due to the Valsalva manoeuvre has been described previously.1 Clinicians should avoid techniques that may lead to a Valsalva manoeuvre in patients with head injuries.
Competing interests None.
Patient consent Obtained.
Provenance and peer review Not commissioned; internally peer reviewed.
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