A 28-year-old woman is brought to the trauma centre 20 minutes after a fall from a 15-foot scaffold. On primary survey: GCS 14 (opens eyes to pain, confused speech, withdraws to pain), airway patent with cervical spine precautions in place, respiratory rate 20/min with oxygen saturation 94% on room air, heart rate 102/min, blood pressure 118/76 mmHg. Pupils are equal and reactive. There is no obvious external bleeding. What is the most appropriate next immediate action?

Explanation

## Management of Moderate Head Injury After High-Energy Trauma **Key Point:** A GCS of 14 following a fall from 15 feet constitutes a **moderate traumatic brain injury (TBI)**. Per ATLS 10th Edition, urgent CT head and cervical spine imaging is the immediate priority in a haemodynamically stable patient with altered consciousness after significant mechanism of injury — it should NOT be deferred until after the secondary survey. ### Primary Survey Assessment | Component | Finding | Status | |-----------|---------|--------| | **A (Airway)** | Patent, C-spine protected | ✓ Secure | | **B (Breathing)** | RR 20, SpO₂ 94% RA | ✓ Adequate (supplemental O₂ indicated) | | **C (Circulation)** | HR 102, BP 118/76 | ✓ Haemodynamically stable | | **D (Disability)** | GCS 14, pupils equal & reactive | ⚠ Altered — requires urgent imaging | | **E (Exposure)** | No obvious bleeding | ✓ Controlled | ### Why Urgent CT Imaging is the Correct Next Step Once the primary survey is complete and the patient is haemodynamically stable, **urgent CT head and cervical spine** is the immediate next action in a patient with: - GCS ≤ 14 after significant mechanism (fall > 1 metre / 5 stairs per NICE/ATLS criteria) - High-energy trauma (15-foot scaffold fall) - Tachycardia that may reflect pain, early shock, or autonomic response to intracranial injury **ATLS 10th Edition** explicitly states that in a stable head-injured patient with altered GCS, CT imaging should be obtained urgently — it is not deferred until after the secondary survey. The secondary survey is performed concurrently or after imaging is arranged, not as a prerequisite to imaging. ### Why Other Options Are Incorrect | Option | Reason Incorrect | |--------|-----------------| | **A — Burr hole** | Reserved for epidural haematoma with herniation signs (unilateral fixed dilated pupil, GCS <8, decerebrate posturing). Pupils are equal and reactive here. | | **B — Proceed with secondary survey first** | Incorrect sequencing. In moderate/severe TBI, imaging is not deferred for secondary survey in a stable patient. | | **D — Empirical mannitol** | Mannitol requires imaging confirmation of raised ICP. Empirical use in a haemodynamically borderline patient (HR 102) risks worsening hypotension and is not indicated without evidence of herniation. | **Clinical Pearl:** GCS 13–14 = moderate TBI. GCS ≤ 8 = severe TBI requiring immediate airway control. This patient's GCS of 14 mandates urgent CT — not empirical treatment, not burr holes, and not deferral to secondary survey. **High-Yield:** Per ATLS and NICE Head Injury Guidelines, any patient with GCS < 15 after significant mechanism should receive CT head within 1 hour of meeting criteria. Haemodynamic stability is the green light for imaging — not completion of secondary survey. [cite: ATLS 10th Edition, Chapter 6 — Head Trauma; NICE CG176 Head Injury Guidelines]