Emergency Medicine · Year 3 · from Emergency Medicine

Case 2: Traumatic Brain Injury with Herniation

Patient Demographics

• Age: 19 years
• Sex: Female
• Occupation: College student

Mechanism of Injury

Pedestrian struck by vehicle at approximately 30 mph. Found unresponsive at scene. Witnessed loss of consciousness immediately after impact.

Prehospital Report

• GCS 6 (E1V2M3) at scene
• Left pupil dilated and sluggish
• Intubated in field for airway protection
• BP 142/90, HR 58

Primary Survey

Airway:

• Intubated, ETT secured at 22cm
• ETCO2 confirmed

Breathing:

• Bilateral breath sounds
• Ventilating well
• SpO2 99%

Circulation:

• BP 158/92, HR 52
• Peripheral pulses strong
• No external hemorrhage

Disability:

• GCS 5T (E1VTM3)
• Left pupil: 6mm, fixed
• Right pupil: 3mm, reactive
• Localizes to pain on right, withdraws on left
• Cushing's triad present: Hypertension, bradycardia, irregular respirations

Exposure:

• Scalp laceration left parietal region
• Left periorbital hematoma
• No other obvious injuries

Clinical Diagnosis

Severe Traumatic Brain Injury with Left Uncal Herniation

Evidence:

• GCS 5T (severe TBI = GCS ≤8)
• Unilateral dilated fixed pupil (ipsilateral CN III compression)
• Contralateral motor posturing
• Cushing's triad

Secondary Brain Injury Prevention

Targets:

• Avoid hypoxia: SpO2 >90%
• Avoid hypotension: SBP >90 (ideally >100)
• Avoid hyperthermia: Target normothermia
• Avoid hyperglycemia: Glucose <180

Herniation Management (ICP Crisis)

Immediate Interventions:

1. Head of bed elevated 30 degrees
2. Head midline (ensure C-collar not too tight)
3. Hypertonic saline 23.4%: 30mL IV push (osmotic therapy)
4. Brief hyperventilation: Target ETCO2 30-35 mmHg (temporizing only)
5. Sedation optimized: Propofol infusion
6. Avoid hyperthermia

Imaging

CT Head (without contrast):

• Large left epidural hematoma (5cm x 3cm x 8cm)
• "Lens-shaped" hyperdensity
• Associated skull fracture crossing middle meningeal artery
• 12mm midline shift to right
• Effacement of left lateral ventricle
• Early uncal herniation

CT Cervical Spine:

• No fracture or malalignment

Neurosurgical Consultation

Operative Indication:

• EDH >30mL
• Significant midline shift
• Neurological deterioration
• Evidence of herniation

Decision: Emergent craniotomy

Operative Course

Left Craniotomy for EDH Evacuation:

• Large organized epidural clot removed
• Bleeding vessel (middle meningeal artery) coagulated
• Brain appeared contused but pulsatile post-evacuation
• ICP monitor placed: Opening pressure 35 mmHg, post-op 12 mmHg
• Bone flap replaced

Post-Operative Course

Immediate Post-Op:

• Left pupil now 4mm and reactive
• ICP maintained <20 mmHg
• CPP maintained >60 mmHg

Day 2:

• Sedation lightened
• Following commands bilaterally
• GCS improved to 10T

Day 5:

• Extubated successfully
• GCS 14 (E4V4M6)
• Left-sided weakness improving

Discharge (Day 14):

• GCS 15
• Mild left hemiparesis (improving)
• Transferred to rehabilitation facility

Epidural Hematoma Key Points

Teaching Points

1. Epidural hematoma classic presentation: LOC, lucid interval, deterioration
2. Dilated pupil = ipsilateral to lesion: CN III compression from uncal herniation
3. Cushing's triad = late sign of herniation: HTN, bradycardia, irregular respirations
4. Hypertonic saline preferred over mannitol: More predictable response, no diuretic effect
5. Hyperventilation is temporizing only: Causes vasoconstriction, can worsen ischemia
6. EDH is surgical emergency: Excellent prognosis with rapid evacuation

Clinical Image

Image Description: Non-contrast CT head demonstrating a large left-sided epidural hematoma with characteristic lens-shaped (biconvex) appearance, significant midline shift, and mass effect.

Attribution: Image from Radiopaedia.org, Case courtesy of Dr. Frank Gaillard. Licensed under CC BY-NC-SA 3.0. Source: https://radiopaedia.org/cases/extradural-haematoma

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