A 25-year-old man sustains a blunt head injury in a road traffic accident. His GCS drops from 14 to 8 over 20 minutes. He becomes unconscious with a fixed dilated right pupil and left hemiparesis. What is the most appropriate immediate management?

• A Administer mannitol 1 g/kg IV and observe for 1 hour
• B Obtain urgent MRI brain for better soft tissue characterization
• C Insert an intracranial pressure monitor and admit to ICU
• D Intubate, hyperventilate briefly, obtain CT head, and prepare for emergent craniotomy ✓

Explanation

A rapidly declining GCS with unilateral fixed dilating pupil and contralateral hemiparesis indicates uncal herniation, typically from an expanding intracranial haematoma. This is a neurosurgical emergency. After intubation and brief controlled hyperventilation as a temporizing measure, urgent CT head followed by emergent craniotomy is indicated. Observation or MRI would delay definitive treatment.

Reference: Bailey and Love's Short Practice of Surgery, 28th ed.

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Written and medically reviewed by the StethoPrep medical team.