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Zorluk: OrtaNeurosurgery

A 22-year-old male is brought to the emergency department via ambulance after being struck on the right side of the head with a baseball bat. Paramedics report that he was briefly unconscious at the scene but awoke and conversed normally during the initial transport. Upon arrival at the emergency department 30 minutes later, he is unresponsive. His Glasgow Coma Scale score is 7 (Eye opening: 2, Verbal response: 2, Motor response: 3). Vital signs are temperature 37.1°C (98.8°F), blood pressure 180/105 mm Hg, heart rate 48/min, and respiratory rate 8/min. Neurologic examination reveals a right pupil that is 7 mm and unreactive to light, and a left pupil that is 3 mm and reactive. A left-sided hemiparesis is noted. Which of the following is the most appropriate next step in the management of this patient?

  1. A
    Admit to the intensive care unit for continuous observation and frequent neurologic checks
  2. B
    Transport to the radiology suite for an emergent non-contrast CT scan of the head
  3. Endotracheal intubation and mechanical ventilationCevap
  4. D
    Await the arrival of the next-of-kin to obtain informed consent for intervention
  5. E
    Administer intravenous sodium bicarbonate

Cevap

Endotracheal intubation and mechanical ventilation
The patient presents with classic signs of an acute epidural hematoma complicated by uncal herniation. This is evidenced by the lucid interval followed by rapid neurologic decline, Cushing triad (hypertension, bradycardia, irregular and depressed respirations), an ipsilateral dilated and fixed pupil (due to compression of the right oculomotor nerve), and contralateral hemiparesis (due to compression of the right cerebral peduncle). In any trauma patient, the Advanced Trauma Life Support (ATLS) protocol dictates prioritizing the airway (ABCs). A Glasgow Coma Scale (GCS) score of 8 or less is an absolute indication for endotracheal intubation to protect the airway and ensure adequate oxygenation and ventilation. Once the airway is secured, the patient should rapidly undergo a non-contrast head CT and emergent surgical decompression.

Adım Adım Çözüm

1
Assess the patient's level of consciousness and vital signs.
GCS is 7, with bradycardia, severe hypertension, and bradypnea (Cushing triad).
To identify life-threatening compromises in airway, breathing, or circulation.
2
Evaluate pupillary and motor findings.
Right unreactive pupil and left hemiparesis.
To localize the neurologic lesion, indicating right-sided uncal herniation.
3
Determine the most immediate life-saving intervention.
Secure the airway via endotracheal intubation.
A GCS < 8 and depressed respirations necessitate definitive airway protection before diagnostic imaging or surgical evacuation.

Anahtar Kavram

Airway management in acute traumatic brain injury with signs of uncal herniation and a Glasgow Coma Scale score less than 8.
Tahmini Süre:1m 30s
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Neurosurgery

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