A 19 year-old man is in a vehicular collision in which he swerved off the road and into a ditch. The car rolled over. He was extricated by the fire department. Initial GCS was 5. He was intubated on the scene. EMS brings him to the ED. About 90 minutes have elapsed since the injury.
In the ED, initial vitals are notable for BP 110/76, HR 114, SpO2 92%, T 37C. Non-contrast head CT (shown here) as well as CTA head/neck are obtained. You are then consulted. You ask them to hold his propofol and fentanyl so that you can properly examine him once you arrive.
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You examine the patient. Sedation and continuous analgesia have been held per your request. He is mechanically ventilated and on a PRVC mode. He is not on any vasopressors. Pupils are sluggish but reactive to light as per quantitative pupillometry. He does not open eyes to any stimuli. He withdraws to pain.
The main abnormality seems to be a thin left-sided convexity SDH (thickness about 3mm at the narrowest point, about 6mm at the thickest point closer to the vertex) with some pneumocephalus. There's very slight midline shift (about 2.5mm). You also made sure to look at the bone window, especially since those bubbles of air caught your eye. There's a comminuted calvarial fracture frontotemporally there too. While not shown here, his vessel imaging was fortunately normal.
The ABCs seem to already be in order: he has a secured airway (intubated in the field for airway protection). The ventilator is taking care of his breathing for him. We'll need to check his EtCO2 and ABG to ensure normocapnia is being targeted (goal PaCO2 35-40). Circulation is good at the moment; no signs of impaired perfusion on physical exam, and he's also normotensive without the use of pressors.
He doesn't take any antiplatelets or anticoagulants, so there's nothing for which to consider reversal. (Even if he did, whether or not he is going to the OR dictates whether there's a benefit of giving platelets.) His post-resuscitation GCS puts him in the "severe TBI" category. Per the CRASH-3 trial, he would not benefit from administration of TXA, even though he presented so early from the time of the injury.
In terms of antiseizure medication prophylaxis, the patient hasn't had any seizures. If his mentation remains poor despite operative intervention (if any) and appropriate ICP control, it'd be very reasonable to investigate with cEEG. Convention has been to start a 7-day course of levetiracetam prophylaxis (phenytoin and valproate aren't recommended as the risks outweigh the benefits). (Though, the current Brain Trauma Foundation guidelines do not recommend for or against ASM prophylaxis due to the dearth of high-quality data. NCS guidelines similarly do not recommend for or against ASM prophylaxis.)
You don't want him to be excessively sedated, but you also don't know what his ICP currently is, so you can ask the ED to restart propofol just to ensure ventilator synchrony and a RASS goal of 0 to -1. The fentanyl drip can be held for now.
The patient has a poor exam. His pupils are reactive. He's presenting within just over an hour from his injury. With his poor GCS and abnormal HCT, ICP monitoring should be performed, as his poor exam could very well be secondary to intracranial hypertension, and controlling this should help improve morbidity and mortality.*
Beyond just the ICP monitor placement (or brain tissue oxygen monitor as well if enrolled in BOOST-3), however, there's another concern. He has a comminuted calvarial fracture with pneumocephalus subjacent to the fracture. At the thickest point, the left convexity SDH is 6mm in thickness. Because of the poor GCS and pneumocephalus, evacuation of the clot is indicated. (Indications for evacuation of an acute SDH include: 1) ≥ 10mm thickness or ≥ 5mm midline shift, 2) decline in GCS ≥ 2 points or asymmetric or non-reactive pupils regardless of hematoma size.)
*The most recent edition of the Brain Trauma Foundation guidelines for TBI actually don't recommend for or against ICP monitoring due to the overall poor level of evidence. Convention (from the immediate prior edition of BTF guidelines) has been to place an ICP monitor for: 1) GCS ≤ 8 and abnormal HCT, 2) GCS ≤ 8 with normal HCT but 2 of the 3 following features present: age > 40, motor posturing, SBP < 90mmHg.
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