How should I manage an adult patient in the emergency department who presents with a Glasgow Coma Scale of 8/15, sudden vomiting and headache followed by loss of consciousness, no fever or meningeal signs, and an upgoing left plantar response?

Emergency Management of GCS 8/15 with Sudden Onset Vomiting, Headache, Loss of Consciousness, and Upgoing Left Plantar

This patient requires immediate airway protection via endotracheal intubation, urgent non-contrast CT brain imaging, and neurosurgical consultation—this presentation suggests a life-threatening intracranial hemorrhage with brainstem compression or mass effect causing both decreased consciousness and focal neurological signs.

Immediate Airway Management (First Priority)

Intubate this patient immediately. With GCS 8/15, this patient meets absolute criteria for emergent intubation 1. Guidelines specify that GCS ≤8 mandates tracheal intubation to protect the airway, prevent aspiration (especially given the vomiting history), and ensure adequate oxygenation 1.

Intubation Protocol:

• Pre-oxygenate and maintain head elevation if possible
• Target blood pressure during intubation: Maintain systolic BP >110 mmHg and MAP >80-90 mmHg 2, 1
• Induction agents: Use high-dose fentanyl (3-5 µg/kg) or alfentanil (10-20 µg/kg), followed by an induction agent that maintains MAP, plus rocuronium 1 mg/kg or suxamethonium 1.5 mg/kg 1
• Avoid hypotension during intubation—have vasopressors (ephedrine, metaraminol) immediately available 1

Post-Intubation Targets:

• PaO₂ ≥13 kPa (approximately 98 mmHg) 1
• PaCO₂ 4.5-5.0 kPa (34-38 mmHg)—avoid hyperventilation unless signs of impending herniation 1
• Avoid hyperoxia—target saturation, don't over-oxygenate

Simultaneous Resuscitation and Hemodynamic Management

While preparing for intubation, establish:

• Two large-bore IV lines
• Arterial line for continuous blood pressure monitoring 3, 4
• Maintain systolic BP >110 mmHg (for intracerebral hemorrhage) or MAP >80 mmHg 2, 1

The upgoing left plantar (Babinski sign) indicates pyramidal tract involvement, suggesting either:

1. Right-sided intracerebral hemorrhage with mass effect
2. Brainstem hemorrhage
3. Subarachnoid hemorrhage with secondary complications

Urgent Diagnostic Workup

Obtain non-contrast CT brain immediately—this is the single most critical diagnostic test 2, 3, 2. The combination of sudden onset, vomiting, headache, rapid loss of consciousness, and focal neurological signs strongly suggests intracranial hemorrhage.

Concurrent Laboratory Tests:

• Complete blood count with platelets
• PT/INR, aPTT
• Basic metabolic panel, glucose
• Toxicology screen (though less likely given focal signs)
• Type and screen

Do not delay CT for laboratory results 2.

Neurological Assessment

Perform rapid focused neurological examination:

• Pupillary response and size (asymmetry suggests herniation)
• GCS motor score if feasible 2
• Brainstem reflexes (corneal, oculocephalic if no c-spine injury, gag)
• Document the upgoing plantar and check the contralateral side

The absence of fever and meningeal signs makes bacterial meningitis less likely, though viral encephalitis remains possible. However, the focal neurological sign (upgoing plantar) and sudden onset strongly favor a structural lesion over infection.

Immediate Neurosurgical Consultation

Contact neurosurgery immediately upon CT confirmation of hemorrhage 2, 1, 2. Patients with life-threatening brain lesions require urgent neurosurgical evaluation and potential intervention 2.

Likely CT Findings and Management:

If Intracerebral Hemorrhage (ICH):

• Admit to neuroscience ICU 3, 4, 5
• Consider ICP monitoring if radiological signs of intracranial hypertension 2
• Maintain systolic BP >140 mmHg (avoid hypotension) but <150 mmHg if within 6 hours and no immediate surgery planned 1
• Reverse any coagulopathy immediately
• Neurosurgical evacuation if indicated (large volume, accessible location, deterioration)

If Subarachnoid Hemorrhage:

• Maintain systolic BP <160 mmHg 1
• Urgent vascular imaging (CTA or angiography)
• Nimodipine for vasospasm prevention
• Secure aneurysm if identified

If Hydrocephalus Present:

• Emergency external ventricular drain placement

Critical Pitfalls to Avoid

1. Do not delay intubation waiting for CT—secure the airway first if patient is deteriorating
2. Do not allow hypotension during intubation or resuscitation—this worsens secondary brain injury 2, 3, 6
3. Do not hyperventilate prophylactically—only use brief hyperventilation (PaCO₂ 4.0-4.5 kPa) if signs of impending uncal herniation 2, 1
4. Do not assume this is "just" a metabolic coma—the focal neurological sign (upgoing plantar) demands structural imaging
5. Do not give hypotonic fluids—use 0.9% saline 1

Monitoring and Ongoing Care

Once stabilized:

• Continuous arterial pressure monitoring 3, 4
• Hourly neurological assessments using GCS 3, 6, 4
• Serial CT imaging if neurological deterioration (GCS drop ≥2 points) 6
• ICP monitoring if comatose with radiological signs of intracranial hypertension 2
• Maintain normothermia, normoglycemia
• Head of bed elevation 30 degrees if no contraindication

The absence of trauma history doesn't exclude traumatic causes entirely, but the clinical picture most strongly suggests spontaneous intracranial hemorrhage requiring immediate neurosurgical evaluation and intensive care management.