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A 24-year-old man is brought to the emergency department after a high-speed motorcycle crash. He was unconscious at the scene. On arrival his GCS is 7 (E1 V2 M4), his pupils are 4 mm and reactive, oxygen saturation 90 percent on room air, blood pressure 96/60 mmHg, heart rate 110/min, and there is an obvious deformity of the right thigh. He has a small laceration over the left temporal region. A non-contrast CT brain shows a biconvex extra-axial hyperdense collection in the left temporal region with 7 mm of midline shift to the right.
Questions
a) What is the diagnosis, and give two reasons this is a neurosurgical emergency? (2 marks)
The diagnosis is an acute extradural (epidural) haematoma of the left temporal region — the biconvex (lens-shaped) extra-axial collection is typical, arising from the middle meningeal artery torn by a temporal skull fracture.
It is a neurosurgical emergency because: (1) it is a rapidly expanding mass lesion producing midline shift (7 mm) and impending uncal herniation; and (2) extradural haematomas lie between the skull and dura, expanding against the relatively non-compliant dura, so deterioration can be abrupt — the classic lucid interval is the warning. Without urgent evacuation the patient will herniate and die.
b) Outline your immediate resuscitation of this patient before and during transfer to CT/theatre. (4 marks)
- Airway with cervical spine control: GCS 7 is an indication for endotracheal intubation (RSI) — the brain cannot tolerate hypoxia; maintain in-line C-spine immobilisation (10 percent of significant head injuries have a cervical spine injury).
- Breathing: high-flow oxygen to maintain SaO2 at least 94 percent / PaO2 over 11 kPa; avoid hypoxia — a single hypoxic episode doubles mortality.
- Circulation: external control of bleeding, two large-bore cannulae, IV fluids and/or blood products to keep SBP over 110 mmHg / MAP over 80; a single hypotensive episode (SBP under 90) doubles mortality.
- Disability: check capillary glucose (exclude hypoglycaemia as a contributor to reduced GCS), pupils and GCS serially; treat seizures.
- Raise ICP-lowering measures: head-up 30 degrees, adequate sedation/analgesia, and osmolar therapy (mannitol 0.25-1 g/kg IV or 3 percent hypertonic saline) while awaiting surgery.
- Adjuncts: crossmatch, coagulation/INR and trauma panel; analgesia; urinary catheter; activate the trauma team and neurosurgery; document the time of injury and mechanism.
c) State the Brain Trauma Foundation targets for intracranial pressure (ICP) and cerebral perfusion pressure (CPP), and three measures to lower a raised ICP. (2 marks)
- ICP treatment threshold: above 22 mmHg; CPP target: 60-70 mmHg (CPP = MAP - ICP). Both hypoxia and hypotension must be corrected to preserve CPP.
- Measures to lower ICP: (1) head-up 30 degrees and midline to aid venous drainage; (2) osmolar therapy — mannitol (0.25-1 g/kg) or 3 percent hypertonic saline; (3) adequate sedation/analgesia (and normocapnia, PaCO2 4.5-5.0 kPa — avoid prophylactic hyperventilation); (4) decompressive craniectomy for refractory raised ICP; (5) normothermia and seizure control.
d) Give two complications of severe traumatic brain injury and one preventive measure for each. (2 marks)
- Secondary brain injury (hypoxia, hypotension, raised ICP) — prevented by meticulous oxygenation, blood-pressure control and ICP management (the single biggest preventable cause of death).
- Early post-traumatic epilepsy — prevented with short-course prophylactic anticonvulsant (phenytoin or levetiracetam for 7 days) in severe TBI; does not prevent late epilepsy.
- Venous thromboembolism — prevented with mechanical prophylaxis immediately and LMWH after 48 hours once bleeding is controlled.
- Aspiration pneumonia / ventilator-associated pneumonia — prevented by early intubation with a protected airway, head-up nursing and good pulmonary toilet.