What is the American Society of Anesthesiologists (ASA) classification and Glasgow Coma Scale (GCS) breakdown for a 25-year-old man with severe left temporoparietal extradural hematoma (EDH) and midline shift, who is hypertensive, bradycardic, and has impaired mental status with incomprehensible sounds, eye opening to pain, and limb extension to pain, and what is the immediate anesthetic management for emergency craniotomy and clot evacuation?

ASA Classification, GCS Breakdown, and Immediate Anesthetic Management

ASA Physical Status Classification

This patient is ASA Class 5E (patient not expected to survive without the operation, emergency surgery). 1 The severe temporoparietal extradural hematoma with midline shift represents an immediately life-threatening condition requiring emergency craniotomy, and the patient has profound neurological impairment with signs of increased intracranial pressure (Cushing's triad: hypertension 162/50 mmHg, bradycardia 45 bpm). 2

Glasgow Coma Scale Breakdown

The patient's GCS is 6 (E2 + V2 + M2):

• Eye Opening (E) = 2: Eyes open to painful stimuli 3, 4
• Verbal Response (V) = 2: Incomprehensible sounds 3, 4
• Motor Response (M) = 2: Extension to painful stimuli (decerebrate posturing) 3, 4

This GCS of 6 mandates immediate intubation, as any GCS ≤8 indicates severe impairment of consciousness with inability to protect the airway. 3, 4

Immediate Anesthetic Management

Pre-Induction Preparation (Simultaneous Actions)

Airway management takes absolute priority and must be secured immediately before any other intervention. 4

• Obtain two large-bore IV lines immediately for rapid fluid and medication administration 5
• Prepare cross-matched blood products and have vasoactive medications ready (ephedrine, metaraminol, noradrenaline) 4
• Position patient with 30-degree head elevation to optimize venous drainage while maintaining cervical spine precautions given fall mechanism 3
• Preoxygenate with 100% oxygen for 3-5 minutes to maximize oxygen reserve 4
• Have difficult airway equipment immediately available, as coma itself is a risk factor for difficult intubation 4

Hemodynamic Optimization Before Induction

Critical pitfall: The patient exhibits Cushing's triad (hypertension, bradycardia, irregular respirations), indicating critically elevated intracranial pressure with impending herniation. 3, 5

• Do NOT treat the hypertension acutely unless systolic BP exceeds 220 mmHg, as this represents a physiologic response to maintain cerebral perfusion pressure against elevated ICP 5
• Target systolic BP >140 mmHg and mean arterial pressure >80-90 mmHg throughout the peri-intubation period 3, 4
• Avoiding hypotension during intubation is paramount, as it can precipitate cerebral herniation in patients with elevated ICP 3, 4

Rapid Sequence Induction Protocol

Use rapid sequence induction with hemodynamic support to prevent hypotension, which would be catastrophic in this patient. 3, 4

Induction agents:

• Etomidate 0.2-0.3 mg/kg IV is preferred as it reduces intracranial pressure during intubation and maintains hemodynamic stability 1
• Alternative: Propofol with vasopressor support, though etomidate is superior for hemodynamic stability in this critically unstable patient 1
• Avoid ketamine despite historical concerns being overstated, as etomidate remains the gold standard for this scenario 1

Neuromuscular blockade:

• Rocuronium 1.2 mg/kg IV for rapid paralysis 4
• Succinylcholine 1.5 mg/kg IV is an alternative but may cause transient ICP elevation 4

Hemodynamic support during induction:

• Administer vasopressor bolus (phenylephrine 100-200 mcg or ephedrine 5-10 mg) immediately before or with induction to counteract the vasodilatory effects of anesthetic agents 3, 4
• Have noradrenaline infusion prepared for immediate initiation if hypotension occurs 4

Intubation Technique

• Perform direct laryngoscopy or video laryngoscopy with minimal manipulation to avoid ICP spikes 3
• Confirm correct endotracheal tube placement immediately using waveform capnography, as absence of a recognizable waveform indicates misplacement 4, 5
• Never assume correct placement without capnographic confirmation, as auscultation and chest wall movement are unreliable 4
• Secure the tube with self-adhesive tape rather than circumferential ties to avoid impairing venous drainage 4

Post-Intubation Ventilator Management

Maintain strict normocapnia and adequate oxygenation to prevent secondary brain injury. 3, 4

• Target PaCO₂ 4.5-5.0 kPa (34-38 mmHg) using continuous capnography 3, 4, 5
• Avoid hyperventilation except as a brief life-saving measure for impending uncal herniation, as it causes cerebral vasoconstriction and worsens ischemia 3, 4, 5
• Target PaO₂ ≥13 kPa (≥98 mmHg) but avoid prolonged hyperoxia 3, 4, 5
• Initiate lung-protective ventilation with tidal volumes 6-8 mL/kg ideal body weight 4

Maintenance of Anesthesia

• Maintain sedation with propofol infusion (50-150 mcg/kg/min) or volatile anesthetic (sevoflurane 0.5-1.0 MAC) 1
• Continue neuromuscular blockade to prevent coughing or straining, which increase ICP 3
• Maintain mean arterial pressure >80-90 mmHg to ensure cerebral perfusion pressure >60-70 mmHg 3, 4

Monitoring Requirements

Comprehensive neuromonitoring is essential throughout the perioperative period. 1

• Place arterial line immediately for continuous blood pressure monitoring and frequent blood gas analysis 4, 5
• Continuous capnography to maintain target PaCO₂ 3, 4, 5
• Pulse oximetry for oxygen saturation monitoring 3, 5
• Temperature monitoring to maintain normothermia (36-37°C) 1, 5
• Urine output monitoring via Foley catheter 1

Critical Pitfalls to Avoid

• Never delay intubation waiting for CT imaging in patients with GCS ≤8; secure the airway first 3, 4
• Never treat the hypertension before securing the airway, as this represents compensatory response to elevated ICP 3, 5
• Never allow hypotension during induction, as even brief periods can precipitate herniation 3, 4
• Never hyperventilate routinely, only as a temporizing measure for acute herniation 3, 4, 5
• Never use circumferential ties to secure the endotracheal tube, as this impairs cerebral venous drainage 4

Surgical Considerations

This patient requires immediate surgical evacuation based on established criteria. 2

• EDH >30 cm³ with midline shift in a patient with GCS <9 and signs of herniation (anisocoria from decerebrate posturing) mandates emergency craniotomy 2
• Craniotomy provides more complete hematoma evacuation compared to burr holes 2
• Time to surgery directly impacts mortality; proceed to OR immediately after airway is secured 2