Severe traumatic brain injury — resuscitation to a refractory-ICP craniectomy decision

Presentation

A 27-year-old unrestrained motorcyclist was thrown from his bike at speed. At the scene he was unconscious; paramedics intubated him and brought him in. In the emergency department his Glasgow Coma Scale is 6 (E1 V1t M4), his pupils are 4 mm and reactive, his oxygen saturation is 96 per cent on a ventilator, his blood pressure is 118/70, and there are no external signs of major extracranial injury.

An urgent non-contrast CT of the head shows a small right temporal contusion, a thin bifrontal traumatic subarachnoid haemorrhage, effacement of the basal cisterns, and loss of the grey–white differentiation consistent with diffuse cerebral swelling — but no surgical mass lesion. An intraparenchymal ICP monitor is placed on arrival in ICU and reads 24 mmHg, climbing to 28 mmHg over the first two hours despite sedation, normocapnia and hyperosmolar therapy.^[3]