An Evidence-Based Approach To Severe Traumatic Brain Injury

Bhat, Rahul MD
Hudson, Korin MD, NREMT-P
Sabzevari, Tina MD
Bruns, John J. Jr MD
Bazarian, Jeffrey J. MD, MPH

¹Assistant Professor of Emergency Medicine, Georgetown University Hospital; Washington Hospital Center, Washington, DC
²Attending Physician, Georgetown University, Washington, DC
³Resident Physician, The George Washington University Hospital, Washington, DC
Peer Reviewers
⁴Clinical Assistant Professor, Department of Emergency Medicine, Mount Sinai School of Medicine, New York, NY
⁵Associate Professor of Emergency Medicine and Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY

Emergency Medicine Practice 10(12):p 1-24, December 2008.

You have just started your shift and the charge nurse informs you that EMS has arrived with a 48-year-old man who was involved in a high-speed motorcycle collision. He was not wearing a helmet. He was initially awake and combative on-scene but became lethargic and unresponsive en route to the hospital. He was intubated by EMS prior to arrival. His pupils are unequal; the left is dilated and unreactive. His blood pressure is 136/78; heart rate is 88; oxygen saturation is 100%. He does not respond to verbal or painful stimuli. You suspect that the patient has a severe traumatic brain injury and realize that any hope for a meaningful recovery depends on your ability to mobilize resources, manage the intracranial pressure, and maintain the cerebral perfusion pressure.

Before you even have time to finalize your plan, the EMS radio comes alive. The paramedics are bringing a 78-year-old woman with a history of dementia from a nursing home. The report notes that she suffered a minor fall yesterday, was “lethargic” this morning, and the staff could not arouse her from her nap this afternoon. According to the paramedics, she has a hematoma on her forehead and is protecting her airway but responds only to painful stimuli by withdrawing. Her vital signs are “stable.” EMS is requesting to use RSI to intubate her prior to transport and you are considering the wisdom of their request.