An 18-year-old high school senior is brought to the emergency room after she was involved in a motor vehicle accident. Upon her arrival to the emergency room, she is minimally responsive, and there is evidence of bleeding from the right side of her head. Her vital signs are as follows: temperature 37.6C (99.6F), blood pressure 182/98 mmHg, heart rate 52 per minute and respiratory rate 6 per minute. Her oxygen saturation is 96% on two liters of oxygen. Her breath smells of alcohol. Physical examination reveals a right pupillary size of 7 mm with minimal response to light. The left pupil is 3 mm with normal pupillary light reflex. The right eye is deviated outwards and downwards. There is bilateral papilledema on funduscopic examination. While in the ER, the patient had an episode of generalized body extension, with adduction and pronation of her upper extremities. There is no evidence of any thoracic or abdominal injuries. Which of the following is the most appropriate next step in the management of this patient?

Question

An 18-year-old high school senior is brought to the emergency room after she was involved in a motor vehicle accident.  Upon her arrival to the emergency room, she is minimally responsive, and there is evidence of bleeding from the right side of her head.  Her vital signs are as follows: temperature 37.6C (99.6F), blood pressure 182/98 mmHg, heart rate 52 per minute and respiratory rate 6 per minute.  Her oxygen saturation is 96% on two liters of oxygen.  Her breath smells of alcohol.  Physical examination reveals a right pupillary size of 7 mm with minimal response to light.  The left pupil is 3 mm with normal pupillary light reflex.  The right eye is deviated outwards and downwards.  There is bilateral papilledema on funduscopic examination.  While in the ER, the patient had an episode of generalized body extension, with adduction and pronation of her upper extremities.  There is no evidence of any thoracic or abdominal injuries.  Which of the following is the most appropriate next step in the management of this patient?

Quizplus · Accepted Answer

Explanation: The above patient has the typical clinical features of elevated intracranial pressure (ICP), most likely secondary to an intracranial hemorrhage from head trauma sustained in the motor vehicle accident. Other causes of elevated intracranial pressure include an intracranial hemorrhage from ruptured aneurysms, bleeding AV malformations, CNS infections, CNS neoplasm, and hydrocephalus. Patients with intracranial hypertension have been classically described to have bradycardia, hypertension and respiratory depression (Cushing's triad). In the early stages, patients complain of headaches, vomiting, blurred vision, and have papilledema on funduscopic examination. Further elevation in the intracranial pressure leads to transtentorial herniation of brain tissue, causing altered levels of consciousness (stupor progressing to coma), dilation of the ipsilateral pupil, third cranial nerve palsy, hemiparesis, decerebrate posturing, and eventually, respiratory arrest. The patient in the above vignette has signs of marked respiratory depression and intracranial hypertension. The most important next step in the management is to rapidly intubate the patient to protect and maintain her airway, in case of a respiratory arrest. (Choice A) Intravenous thiamine is useful in alcoholic patients with severe malnutrition to prevent the development of Wernicke's encephalopathy. It has no role in the lowering of an elevated intracranial pressure. (Choice B) CT scan of the brain should be done urgently to look for an intracranial hemorrhage or any other potentially reversible causes of elevated intracranial pressure; however, the patient's airway should be secured before sending her for neuroimaging. (Choice C) Intravenous mannitol is an osmotic diuretic which reduces brain volume by drawing water out of the cells. It can be used to acutely lower elevated intracranial pressures in emergent situations; however, securing and maintaining a patent airway should still remain the first priority in the management of such patients. (Choice D) Lowering the PaCO2 by hyperventilating the patient causes cerebral vasoconstriction, which decreases the cerebral blood flow, and reduces intracranial pressure. Hyperventilation is therefore used to decrease the PaCO2 to 25-30 mmHg and to rapidly lower intracranial pressure in emergent situations; however, it is contraindicated in patients with traumatic brain injury and an acute stroke. This is due to the fact that a significant decrease in cerebral blood flow caused by vasoconstriction can lead to worsening of neurological injury in these patients. Educational objective: Securing and maintaining a patent airway is the first priority in the management of trauma patients with symptomatic intracranial hypertension.

An 18-Year-Old High School Senior Is Brought to the Emergency