Extradural haematoma — the lucid interval

Diagnosis. This is an expanding extradural (epidural) haematoma with the uncal herniation syndrome. The lucid interval (brief LOC, then a normal GCS, then a falling GCS), the temporal-impact mechanism, the ipsilateral fixed dilated pupil (the third-nerve compression at the tentorial hiatus), and the contralateral signs, with the Cushing response (the hypertension and the bradycardia), are the textbook presentation. Do NOT wait for the CT to act. Airway. GCS 12 and falling — this patient will need a definitive airway. Prepare the rapid-sequence induction now with the cervical spine in-line stabilisation, using a neuroprotective induction (propofol or thiopental; ketamine acceptable). Preoxygenate, confirm with the capnography. Breathing. Ventilate to the normocapnia (PaCO2 35 to 40 mmHg). The unilateral fixed pupil with the falling GCS is the ONE situation where the transient hyperventilation (to PaCO2 30 to 35 mmHg) is justified as a bridge while the osmotherapy is drawn up — for minutes, not hours. Circulation. Maintain the SBP at or above 110 mmHg; this patient is currently 160/90 — do not lower it (the hypertension is the Cushing response defending the cerebral perfusion). Maintain with the fluid and the vasopressor as needed. Osmotherapy. Give the mannitol 0.5 g per kg intravenously immediately (or the hypertonic saline 3 per cent 250 mL) for the uncal herniation. Elevate the head to 30 degrees in the neutral position. Ensure the normoglycaemia and the normothermia. Imaging and referral. Once intubated and stable, the urgent CT head (the non-contrast CT) — it will show the lentiform biconvex collection at the right pterion with the mass effect. Call the neurosurgeon immediately, in parallel with the CT, for the urgent craniotomy — this patient meets the surgical threshold and the minutes decide the outcome. Corticosteroids. Do NOT give the corticosteroids — CRASH randomised 10,008 adults to a 48-hour methylprednisolone infusion or placebo and death within 2 weeks was higher with steroids (21.1 per cent vs 17.9 per cent; RR 1.18).^[5] Cervical spine. Assume the cervical spine is injured until cleared — the in-line stabilisation throughout, and the imaging once stabilised.