A 24 year-old male presents to the Emergency Department (ED) with traumatic injury following a collision of his motorcycle with an automobile. Responding police officers and paramedics had obtained information regarding the accident from witnesses, and relay that information to ED staff. The patient was not wearing a helmet, and was at a standstill in a traffic jam. When traffic began to move, at 15-20 mph, a motorist quickly swerved into the patient's driving lane, colliding with the patient and his motorcycle. The patient was thrown 12 feet from the roadway and landed in a shallow ditch, which contained mixed grasses and rocks.

General Appearance: The patient is lying supine, and opens his eyes when addressed. Verbal responses are inarticulate (but consist of words), and he is mumbling in a deep, but weak voice. He is not alert to his surroundings or circumstance. He pulls his hand away when pressure is applied to the nailbed. Blood pressure is 130/90, heart rate is 78, and respiratory rate is 20. The patient is 6'6" tall, and weighs approximately 225 lbs. Other pertinent physical findings are as follows:

Cardiovascular: Regular rate and rhythm. PMI not displaced.

Integument: Multiple contusions and abrasions over the flanks and extremities. Patchy hyperpigmentation of the chest and abdomen. Multiple (greater than 20) acrochorda (skin tags), predominately on the shoulders. An 8.0 cm black-ink tattoo in the shape of a half moon is present over the right scapula.

HEENT: Multiple lacerations and a 10 cm diameter contusion over the occiput. Non-traumatic thickening of the frontal brow region.

Musculoskeletal: Slight thickening of fingers, with blunting of the fingertips. Thickened fingernails.

Pulmonary: Clear to percussion and auscultation.