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Difficulty: HardInitial Stabilization and Triage

A 24-year-old man is brought to the emergency department by paramedics after being ejected from a motorcycle during a high-speed collision. He was not wearing a helmet. On arrival, he is unresponsive. The paramedics report that his Glasgow Coma Scale score was initially 9 at the scene but has progressively declined to 6 (Eye opening: 1, Verbal response: 2, Motor response: 3) during transport. Vital signs are temperature 36.2°C (97.1°F), blood pressure 185/105 mm Hg, heart rate 48/min, and respiratory rate 8/min with an irregular pattern. Physical examination reveals a large right temporoparietal scalp hematoma. The right pupil is 7 mm and nonreactive to light, while the left pupil is 3 mm and briskly reactive. There is no active external hemorrhage, and the pelvis is stable to palpation. Breath sounds are equal bilaterally. Which of the following is the most appropriate initial step in the management of this patient?

  1. Endotracheal intubation with rapid sequence inductionAnswer
  2. B
    Transport to the radiology suite for a non-contrast head computed tomography scan
  3. C
    Intravenous administration of 20% mannitol
  4. D
    Urgent consultation with neurosurgery for operative intervention
  5. E
    Intravenous administration of labetalol

Answer

Endotracheal intubation with rapid sequence induction is the most appropriate initial step in management.
The correct answer is endotracheal intubation with rapid sequence induction. This patient is presenting with classic signs of severe traumatic brain injury (TBI) and impending uncal herniation, indicated by his declining Glasgow Coma Scale (GCS) score, right-sided pupillary dilation (oculomotor nerve compression), and Cushing triad (hypertension, bradycardia, and irregular respirations). In any major trauma, the absolute first priority is adhering to the Advanced Trauma Life Support (ATLS) protocols, beginning with securing the Airway and ensuring adequate Breathing (ABCs). A GCS score of 8 or less is an absolute indication for endotracheal intubation. This intervention protects the airway from aspiration and ensures adequate oxygenation and ventilation, which is critical because hypoxia and hypercapnia rapidly exacerbate cerebral edema and secondary brain injury. Only after the airway is secured should the patient undergo definitive diagnostic imaging and targeted intracranial pressure management.

Step-by-Step Solution

1
Evaluate the patient's level of consciousness and airway patency.
The patient has a GCS of 6 and irregular, slow respirations.
The ATLS primary survey dictates assessing Airway and Breathing first in any trauma patient.
2
Identify the signs of impending uncal herniation.
The patient exhibits Cushing triad (hypertension, bradycardia, irregular respirations) and a unilateral dilated, nonreactive pupil.
Recognizing this syndrome is crucial for anticipating the need for subsequent neurosurgical intervention and ICP management.
3
Prioritize interventions based on the primary survey.
Endotracheal intubation is selected as the immediate next step.
While ICP management and definitive imaging are necessary, securing the airway takes absolute precedence in an unresponsive patient with a GCS ≤ 8.

Key Concept

In patients with severe traumatic brain injury and signs of herniation, securing the airway (GCS ≤ 8) takes absolute precedence over diagnostic imaging, subspecialty consultation, and targeted intracranial pressure management.
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Topics

Initial Stabilization and Triage

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