Emergency management of severe TBI

Airway. GCS 6 — this patient needs a definitive airway immediately. Perform RSI with cervical spine in-line stabilisation, using a neuroprotective induction (propofol or thiopental; ketamine acceptable). Preoxygenate, confirm with capnography.^[5] Breathing. Ventilate to normocapnia (PaCO2 35 to 45) — the control arm of the hyperventilation trial. Do NOT hyperventilate routinely: prophylactic hyperventilation to PaCO2 25 gave fewer favourable outcomes at 3 and 6 months. Maintain SpO2 above 94 per cent. The right pupil dilation with the GCS 6 indicates the herniation syndrome — this is the ONE situation where transient hyperventilation (to PaCO2 30 to 35) is justified while the osmolar therapy is prepared.^[4] Circulation. Maintain SBP at or above 110 — early hypotension (systolic under 90) doubled mortality (55% versus 27%). This patient is currently 120/80 — maintain it with fluid and vasopressor as needed.^[5] Osmolar therapy. The unilateral fixed dilated pupil with the falling GCS is the herniation. Give mannitol 0.5 to 1 g per kg IV (or hypertonic saline 3 per cent bolus) immediately to lower the ICP — no difference was found between hypertonic saline and mannitol for ICP reduction, so guide the choice by patient parameters. Elevate the head to 30 degrees. Ensure normoglycaemia, normothermia.^[3] Corticosteroids. Do NOT give corticosteroids — the CRASH trial (10,008 adults) found methylprednisolone raised death within two weeks (21.1% versus 17.9%; relative risk 1.18).^[2] Imaging and referral. Urgent CT head (once intubated and stable enough for the short transfer). The CT will show the likely extradural or subdural haematoma. Call the neurosurgeon immediately — this patient likely needs the urgent surgical evacuation (craniotomy or decompressive craniectomy). The window is narrow.^[1]