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Difficulty: MediumNeurosurgery

A 22-year-old man is brought to the emergency department by emergency medical services after being ejected from a motorcycle at high speed. He was not wearing a helmet. Upon arrival, he does not open his eyes to pain, makes incomprehensible sounds, and exhibits abnormal extension of his upper extremities to painful stimuli. His right pupil is 7 mm and nonreactive to light, while the left is 3 mm and reactive. Blood pressure is 165/95 mmHg, heart rate is 55/min, and respiratory rate is 10/min and irregular.

Arrange the following interventions in the correct chronological order from FIRST to LAST in the acute management of this patient.

  1. 1Secure the airway via endotracheal intubation
  2. 2Administer an intravenous bolus of hyperosmolar therapy
  3. 3Transport the patient for a non-contrast CT scan of the head
  4. 4Transfer the patient to the operating room for surgical decompression

Answer

The correct sequence is: securing the airway, administering hyperosmolar therapy, obtaining a CT scan of the head, and finally performing surgical decompression.
The established trauma protocol requires securing the airway first (ABC priorities). Subsequent management of acute herniation requires immediate temporizing medical therapy (hyperosmolar agents) to reduce intracranial pressure, followed by diagnostic imaging to locate the lesion, and ultimately definitive surgical decompression.

Step-by-Step Solution

1
Assess the patient's airway and Glasgow Coma Scale (GCS) score.
The GCS is 5 (Eyes 1, Verbal 2, Motor 2), mandating immediate endotracheal intubation.
Protection of the airway takes precedence in all trauma resuscitation protocols (ATLS) to prevent hypoxia-induced secondary brain injury.
2
Recognize signs of increased intracranial pressure and active herniation.
Initiate temporizing medical therapies, such as intravenous hypertonic saline or mannitol, immediately.
The patient has a unilaterally blown pupil and Cushing triad (hypertension, bradycardia, irregular respirations); osmotic agents rapidly reduce brain volume to prevent fatal brainstem compression while preparing for imaging.
3
Determine the underlying structural cause of the patient's neurologic collapse.
Obtain a non-contrast CT scan of the head.
Imaging is necessary to definitively locate the exact size and position of any intracranial hemorrhage or structural lesion before surgical intervention.
4
Provide definitive management for the intracranial lesion.
Proceed to the operating room for a decompressive craniotomy or hematoma evacuation.
Surgical decompression is the ultimate lifesaving step for a reversible, space-occupying intracranial lesion.

Key Concept

Prioritization of acute management in severe traumatic brain injury with active brain herniation.
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Neurosurgery

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