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Difficulty: MediumNeurosurgery

A 34-year-old woman is brought to the trauma bay via ambulance after being ejected from a rolling vehicle. Paramedics report she has been unresponsive since their arrival 20 minutes ago and intubated her at the scene. Current vital signs include a temperature of 36.2°C (97.2°F), blood pressure of 72/40 mm Hg, heart rate of 145/min, and respiratory rate of 28/min. Neurological evaluation reveals a Glasgow Coma Scale score of 3T. Her right pupil is 7 mm and unreactive to light; the left pupil is 3 mm and briskly reactive. Physical examination is notable for a large, actively bleeding laceration with a palpable step-off over the right temporal bone, as well as a tensely distended, rigid abdomen. Intravenous access is established, and a rapid infusion of 2 L of warmed crystalloid does not improve her blood pressure. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Right-sided exploratory burr hole
  2. B
    Noncontrast computed tomography of the head
  3. Focused assessment with sonography for traumaAnswer
  4. D
    Intravenous administration of mannitol
  5. E
    Intravenous administration of broad-spectrum antibiotics

Answer

Focused assessment with sonography for trauma
The correct answer is focused assessment with sonography for trauma (FAST). This patient presents with a severe traumatic brain injury (TBI) complicated by signs of right uncal herniation (blown right pupil, GCS 3T, temporal bone step-off). However, she is also in profound hemorrhagic shock (blood pressure 72/40 mm Hg despite 2 L of crystalloid) with a rigid abdomen, strongly suggesting massive intraperitoneal hemorrhage. According to Advanced Trauma Life Support (ATLS) principles, securing the airway, breathing, and circulation (ABCs) takes absolute priority. Cerebral perfusion pressure (CPP) is equal to mean arterial pressure (MAP) minus intracranial pressure (ICP). If systemic blood pressure is not rapidly restored, treating the ICP alone will not restore blood flow to the brain, and the patient will die from exsanguination. Furthermore, a hemodynamically unstable patient must never be transported to the CT scanner. A FAST exam is the most appropriate next rapid diagnostic step to confirm intra-abdominal bleeding before proceeding to an emergent exploratory laparotomy.

Step-by-Step Solution

1
Evaluate the patient's vital signs and primary survey.
The patient is in severe hemorrhagic shock (hypotension, tachycardia) and has a rigid, distended abdomen, indicating a likely massive intra-abdominal hemorrhage.
Advanced Trauma Life Support (ATLS) protocols dictate that circulation (C) must be secured to maintain vital organ perfusion before addressing localized injuries.
2
Analyze the neurological findings.
The patient has a GCS of 3T and a blown right pupil, indicating uncal herniation likely secondary to an epidural or subdural hematoma underlying the temporal bone fracture.
A palpable step-off over the temporal bone with asymmetric pupillary dilation strongly suggests an expanding intracranial hemorrhage.
3
Prioritize interventions based on ATLS guidelines.
Diagnostic evaluation of the hemorrhagic shock (FAST exam) takes precedence over neurological imaging (CT head) or targeted intracranial pressure reduction.
A patient who is hemodynamically unstable cannot safely leave the trauma bay for a CT scan, and cerebral perfusion depends entirely on adequate systemic mean arterial pressure.

Key Concept

In polytrauma patients with concurrent severe traumatic brain injury and hemorrhagic shock, identifying and treating the source of systemic bleeding must precede transport for neuroimaging, because cerebral perfusion relies on systemic blood pressure and unstable patients may arrest in the CT scanner.
Estimated Time:1m 15s
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Topics

Neurosurgery

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