What is the management plan for a 22-year-old male with loss of consciousness after a road traffic accident, including necessary labs and important considerations?

Management of 22-Year-Old Male with Loss of Consciousness After Road Traffic Accident

This patient requires immediate transfer to a specialized neurosurgical center with urgent head and cervical spine CT imaging, aggressive hemodynamic management maintaining systolic blood pressure >110 mmHg at all times, and close neurological monitoring to prevent secondary brain injury and death. 1, 2

Immediate Priorities

Airway and Breathing Assessment

• Secure airway immediately if Glasgow Coma Scale (GCS) is ≤8 or if there is risk of deterioration 2
• Maintain end-tidal CO₂ between 30-35 mmHg to prevent both hypercapnia (which increases intracranial pressure) and hypocapnia (which reduces cerebral perfusion) 1
• Monitor respiratory status continuously as hypoxia will worsen brain injury 3

Hemodynamic Management - Critical Priority

• Maintain systolic blood pressure >110 mmHg at all times—even a single episode below this threshold markedly increases mortality and worsens neurological outcomes 1, 2
• Use vasopressors (phenylephrine or norepinephrine) immediately if hypotension develops rather than waiting for fluid resuscitation effects 3, 4
• Avoid hypotensive sedative agents during initial management 4, 2

Neurological Assessment

• Calculate GCS score immediately, documenting all three components (eye opening, verbal response, motor response) 1
• Classify severity: severe TBI (GCS ≤8), moderate TBI (GCS 9-13), mild TBI (GCS 14-15) 2
• Assess pupillary size and reactivity bilaterally 3
• Document any focal neurological deficits, motor strength in all extremities, and cranial nerve examination 3

Imaging Strategy

Urgent CT Imaging

• Perform brain and cervical spine CT scan without delay—this is mandatory regardless of GCS score given the history of loss of consciousness after motor vehicle crash 1, 2
• Use bone windows with double fenestration (central nervous system and bone windows) to fully characterize injuries 1, 4
• Even patients with GCS 15 require CT imaging if they have loss of consciousness, as up to 15% will have acute intracranial lesions 1

CT Angiography Indications

• Obtain CT angiography of supra-aortic and intracranial vessels urgently if any of the following are present: 1, 4, 2
  • Signs of basilar skull fracture (rhinorrhea, otorrhea, hemotympanum, retroauricular hematoma, periorbital hematoma)
  • Displaced skull fracture
  • Focal neurological deficits
  • High-energy mechanism (motor vehicle crash qualifies)

Laboratory Investigations

Essential Labs

• Complete blood count (CBC) to assess for anemia and thrombocytopenia 3
• Coagulation studies (PT/INR, aPTT) especially critical if patient is on anticoagulants or antiplatelets 1, 3
• Basic metabolic panel to assess electrolytes, renal function, and glucose 3
• Arterial blood gas to guide ventilation management and assess acid-base status 1
• Blood alcohol level and toxicology screen given motor vehicle crash mechanism 3
• Type and screen in preparation for potential neurosurgical intervention 3

Biomarkers NOT Recommended

• Do not use biomarkers (S100b, NSE, UCH-L1, GFAP) in clinical routine for initial severity assessment, as uncertainties remain regarding normal ranges and clinical utility 1, 2

Critical Information to Elicit

Medication History - Highest Priority

• Determine immediately if patient is taking anticoagulants (warfarin, DOACs) or antiplatelet agents (aspirin, clopidogrel)—this is vital for management 3, 4
• Document all current medications including recent changes 3

Mechanism Details

• Exact speed of vehicle, use of seatbelt/airbag deployment, ejection from vehicle, damage to vehicle 3
• Witnessed loss of consciousness duration, any seizure activity 1
• Time from injury to presentation 3

Medical History

• Pre-existing conditions: hypertension, diabetes, prior stroke/TIA, atrial fibrillation, chronic kidney disease 3
• Baseline functional and cognitive status 3
• History of prior head injuries or seizures 1

Transfer and Admission Criteria

Immediate Transfer to Neurosurgical Center

• All severe TBI patients (GCS ≤8) must be transferred immediately to a specialized center with neurosurgical facilities—this significantly reduces mortality and improves neurological outcomes 1, 2
• Moderate TBI patients (GCS 9-13) should also be transferred to neurosurgical centers 2

Admission Criteria for Mild TBI (GCS 14-15)

• Any loss of consciousness requires admission for observation, even with GCS 15 4, 2
• High-risk features requiring admission include: 1
  • Signs of basilar skull fracture
  • Displaced skull fracture
  • Post-traumatic seizure
  • Focal neurological deficit
  • Coagulation disorders or anticoagulant therapy

Neurosurgical Consultation

Immediate Consultation Required For:

• Acute subdural or epidural hematoma 3, 2
• Multiple hemorrhagic contusions 3
• Significant mass effect or midline shift 3, 2
• Deteriorating neurological examination 1, 2
• GCS ≤8 (severe TBI) 2

Monitoring Requirements

Intensive Care Monitoring

• Continuous neurological assessment with serial GCS measurements 3, 2
• Continuous cardiac monitoring 3
• Strict blood pressure management with continuous arterial line if severe TBI 2
• Repeat CT head within 6-12 hours if initial scan shows intracranial injury 3, 4
• Consider intracranial pressure monitoring if neurological deterioration occurs 3

Transcranial Doppler (Optional)

• May be used to assess brain perfusion; concerning findings include diastolic flow velocity <20 cm/s and pulsatility index >1.4 1, 2

Specific Treatments

Intracranial Pressure Management (If Indicated)

• For persistent intracranial hypertension, perform external ventricular drainage as first-line intervention 2
• Mannitol 0.25 to 2 g/kg IV over 30-60 minutes for reduction of intracranial pressure 5
• Hypertonic saline for clinical transtentorial herniation 2

Medications to AVOID

• Do NOT use corticosteroids for TBI management—they provide no benefit on mortality or neurological outcomes 2

Critical Pitfalls to Avoid

• Never allow any episode of arterial hypotension below SBP 110 mmHg—prevention is critical 4, 2
• Do not discharge patients with loss of consciousness without adequate observation period, even if GCS is 15 4, 2
• Do not miss anticoagulation status—this must be determined immediately 3, 4
• Do not delay CT imaging—it must be performed without delay 1, 2
• Do not miss associated vascular injuries—obtain CT angiography in high-risk patients 4, 2
• Do not use hypotensive sedative agents during initial management 4, 2

Special Considerations for This Age Group

• Males aged 15-24 years have the highest incidence of mild TBI from motor vehicle crashes 1
• Despite young age, 5-15% of patients with mild TBI may have compromised function 1 year after injury 1
• Post-traumatic stress disorder and psychiatric complications are common even with brief unconsciousness 6