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Question

Difficulty: MediumInitial Stabilization and Triage

A 22-year-old male university student is transported to the emergency department after falling approximately 3 meters (10 feet) from a balcony and striking his head on concrete. Emergency medical services report that he was initially conversant at the scene but became increasingly somnolent during transit. Upon arrival, he does not open his eyes to pain, makes no verbal sounds, and withdraws his left arm from painful stimuli. Vital signs demonstrate a blood pressure of 185/105 mmHg, a heart rate of 48/min, and a respiratory rate of 8/min with irregular breathing patterns. Physical examination reveals a right pupil that is 7 mm and unresponsive to light, while the left pupil is 3 mm and briskly reactive. Which of the following is the most appropriate immediate next step in management?

  1. A
    Obtain an urgent computed tomography scan of the head
  2. B
    Administer a bolus of intravenous hypertonic saline
  3. Secure the airway with orotracheal intubationAnswer
  4. D
    Request an immediate neurosurgical consultation for cranial decompression
  5. E
    Administer an intravenous antihypertensive agent

Answer

Secure the airway with orotracheal intubation
The most appropriate immediate next step is securing the airway with orotracheal intubation. This patient presents with a severe traumatic brain injury following a 'lucid interval,' classically associated with an epidural hematoma. His Glasgow Coma Scale (GCS) score is 6 (Eyes: 1, Verbal: 1, Motor: 4), and he exhibits clear signs of uncal herniation (ipsilateral fixed and dilated pupil) along with Cushing's triad (hypertension, bradycardia, and irregular respirations). According to standard trauma resuscitation protocols (ATLS), airway maintenance with simultaneous cervical spine protection is the paramount initial step. Any patient with a GCS of 8 or less cannot reliably protect their airway and requires immediate endotracheal intubation to prevent hypoxia and hypercapnia, which would further exacerbate secondary brain injury.

Step-by-Step Solution

1
Calculate the patient's Glasgow Coma Scale (GCS) score.
The GCS score is 6 (Eyes: 1, Verbal: 1, Motor: 4).
To objectively quantify the level of consciousness and determine the need for airway protection.
2
Analyze the vital signs and pupillary findings.
The patient exhibits Cushing's triad (hypertension, bradycardia, irregular respirations) and an ipsilateral blown pupil.
These findings indicate severely elevated intracranial pressure and impending uncal herniation.
3
Prioritize interventions based on Advanced Trauma Life Support (ATLS) protocols.
Airway protection is identified as the absolute first priority.
A patient with a GCS of 8 or less cannot reliably protect their airway, making intubation the paramount first step before any diagnostic testing or secondary interventions.

Key Concept

In patients with severe traumatic brain injury (GCS of 8 or less), securing a definitive airway is the absolute first priority in the primary survey, preceding diagnostic imaging or medical management of intracranial pressure.
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Topics

Initial Stabilization and Triage

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