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Difficulty: HardInitial Stabilization and Triage

Emergency medical services bring a 19-year-old college student to the emergency department after he fell approximately 15 feet from a balcony. Paramedics report he was briefly conscious at the scene but rapidly became unresponsive during transport.

On arrival, his eyes are closed, he makes no vocal sounds, and he extends his upper extremities in response to painful stimuli.

Vital signs include a blood pressure of 190/100 mmHg, a heart rate of 48/min, a respiratory rate of 8/min with an irregular pattern, and an oxygen saturation of 89% despite a non-rebreather mask.

Primary survey reveals a boggy swelling over the right parietal area. Neurologic examination shows a right pupil measuring 7 mm and unreactive to light, while the left pupil is 3 mm and reactive.

Arrange the following patient management steps in the most appropriate chronological sequence.

  1. 1Perform rapid sequence endotracheal intubation
  2. 2Administer an intravenous bolus of hypertonic saline
  3. 3Obtain a non-contrast computed tomography (CT) scan of the head
  4. 4Consult neurosurgery for emergent operative decompression

Answer

The correct chronological sequence is to first secure the airway via intubation, then medically treat the elevated intracranial pressure with hyperosmolar therapy, followed by obtaining a CT scan of the head, and finally consulting neurosurgery for operative intervention.
This patient presents with a severe traumatic brain injury (GCS 4) and signs of impending uncal herniation, indicated by the Cushing reflex (hypertension, bradycardia, irregular respirations) and a unilateral blown pupil. According to Advanced Trauma Life Support (ATLS) principles, the first step in management is always to secure the airway in any patient with a GCS of 8 or less. Following intubation, the immediate life-threat of brain herniation must be medically temporized using hyperosmolar therapy (such as hypertonic saline or mannitol) to reduce intracranial pressure. Only after the airway is secured and the herniation is medically stabilized should the patient be moved from the resuscitation bay to the radiology suite for a non-contrast CT of the head. Finally, once the exact location and extent of the hemorrhage are identified on the scan, neurosurgery is consulted for definitive operative decompression.

Step-by-Step Solution

1
Assess the patient's Glasgow Coma Scale (GCS) and airway patency.
The GCS is 4 (Eyes 1, Verbal 1, Motor 2), indicating an inability to protect the airway.
Advanced Trauma Life Support (ATLS) protocol dictates that securing the airway is the immediate first priority, especially when hypoxia and irregular respirations are present.
2
Identify signs of severely elevated intracranial pressure (ICP) and brain herniation.
The patient exhibits the Cushing reflex (hypertension, bradycardia, irregular breathing) and a unilateral dilated, unreactive pupil (uncal herniation).
These findings indicate a life-threatening neurological emergency requiring immediate medical temporization (e.g., hypertonic saline or mannitol) prior to moving the patient.
3
Determine the appropriate timing for diagnostic imaging.
A non-contrast CT scan of the head is obtained only after the airway is secure and hyperosmolar therapy has been initiated.
Transporting an unstable, herniating patient to the scanner without securing the airway or treating the ICP can result in fatal respiratory arrest.
4
Arrange for definitive surgical treatment.
Neurosurgery is consulted for operative decompression.
The precise surgical approach depends on the structural data provided by the CT scan, making consultation the final step in this initial triage sequence.

Key Concept

In severe traumatic brain injury with signs of herniation, primary survey airway securement and medical temporization of intracranial pressure must precede diagnostic imaging and surgical intervention.

Alternative Method

Intravenous mannitol is a valid alternative to hypertonic saline for the medical temporization of elevated intracranial pressure, provided the patient is not hypotensive.
Estimated Time:2m 0s
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Topics

Initial Stabilization and Triage

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