A 42-year-old woman is admitted to the trauma ICU 4 hours after a motor vehicle collision. She was initially alert (GCS 15) but has now deteriorated to GCS 8 (E2V2M4). CT head shows a 15 mm right acute subdural haematoma with 8 mm midline shift and compressed right lateral ventricle. Pupils are 4 mm bilaterally and reactive. Vitals: BP 168/104, HR 92, RR 22, SpO₂ 94% on room air. What is the most appropriate next step in management?

Explanation

## Clinical Diagnosis This patient has an **acute subdural haematoma with signs of increased intracranial pressure (ICP) and herniation risk**: - GCS decline from 15 to 8 (critical threshold for airway protection) - Midline shift 8 mm (significant mass effect) - Elevated blood pressure and respiratory rate (Cushing's triad beginning) - Pupils still reactive (not yet fixed — window for intervention) ## Immediate Management Priorities ```mermaid flowchart TD A[Acute SDH + GCS 8 + midline shift]:::outcome --> B[Airway protection]:::action B --> C[Intubation + sedation]:::action C --> D[ICP reduction]:::action D --> E[Hyperventilation to PaCO₂ 30-35]:::action D --> F[Mannitol 1 g/kg IV]:::action E --> G[Neurosurgical evacuation]:::action F --> G ``` ## Key Management Steps ### 1. Airway & Ventilation **High-Yield:** GCS ≤ 8 = **cannot protect airway**. Intubation is mandatory. - Use rapid sequence intubation with minimal hypoxia. - Hyperventilate to **PaCO₂ 30–35 mmHg** (causes cerebral vasoconstriction, reduces ICP acutely). - Avoid hypoxia (PaO₂ > 100 mmHg) and hypercapnia. ### 2. Osmotic Therapy - **Mannitol 1 g/kg IV bolus:** Onset 15–30 min, peak effect 30–60 min. Reduces ICP by 30–50%. - Alternative: Hypertonic saline (3% or 7.5%) if mannitol contraindicated (renal failure, hyperkalemia). ### 3. Neurosurgical Consultation & Evacuation - **Acute SDH with mass effect and GCS decline requires operative evacuation** — do not delay. - Burr holes or craniotomy depending on haematoma thickness and surgeon preference. **Clinical Pearl:** The "golden hour" concept applies: outcomes worsen dramatically if evacuation is delayed beyond 4 hours from injury in symptomatic patients. This patient is at 4 hours — urgent transfer is critical. **Warning:** Do NOT rely on medical management alone for mass lesions. Steroids (dexamethasone) have no role in acute subdural haematoma and delay definitive treatment. **Mnemonic:** **ABCDE for ICP**: - **A**irway (intubate if GCS ≤ 8) - **B**reathing (hyperventilate PaCO₂ 30–35) - **C**irculation (maintain MAP > 65) - **D**rugs (mannitol, hypertonic saline) - **E**vacuation (neurosurgery) [cite:ATLS 10th Edition Ch 4; Neurosurgery Principles of Management]