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Neuroanaesthesia · Core07 / 14
Head injury with haemorrhagic shock for laparotomy24-year-old man, 80 kg, motorcycle crash 90 minutes ago; GCS 9 (E2 V2 M5)
Head injury with bleeding: cerebral perfusion versus haemorrhage control priorities
From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.
Know this first
SBP at least 110 mmHg for ages 15–49 and over 70; at least 100 mmHg for 50–69.
One SBP under 90 mmHg doubles mortality after severe head injury.
No permissive hypotension with brain or cord injury.
CPP 60–70 mmHg once ICP is monitored.
Prolonged hyperventilation to a PaCO2 of 25 mmHg or less is not recommended.
The patient
24-year-old man, 80 kg, motorcycle crash 90 minutes ago; GCS 9 (E2 V2 M5), small right frontal contusion on CT.
FAST positive with a liver laceration; smells of alcohol; cervical collar on.
For emergency laparotomy now.
Vitals: BP 84/50, HR 132, SpO2 93% on 15 L/min mask, RR 28; pupils equal and reactive; Hb 9.1 g/dL.
The examiner asks
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Consider
What are your priorities?
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A 24-year-old with a head injury and a bleeding liver, for emergency laparotomy. Patient
xABCDE: his bleeding liver comes first; induction may drop his 84 systolic further.
GCS 9 with a contusion: his brain can't tolerate hypotension or hypoxia. Disease
His neck isn't cleared, so I assume a cervical spine injury. Airway
The liver team may want a low pressure; his brain needs a higher one. Surgery
Plan
How will you anaesthetise him?
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RSI with manual inline stabilisation; the collar front comes off for laryngoscopy. Airway
Induction titrated to avoid any drop in pressure; ketamine suits him.
Rocuronium 1.2 mg/kg for the RSI.
Systolic 110 or more at 24 (BTF); ATLS 11 floor 100–110; CPP 60–70 once ICP is measured. Disease
SpO2 above 95%, and he's only 93% now; PaCO2 normal, no routine hyperventilation.
No hypotonic or glucose-containing fluids; they worsen cerebral oedema.
Neurosurgeons involved now; ICP monitoring considered at the end. After surgery
Crisis
On opening, blood pours out of the abdomen; BP 62/35, HR 150. What do you do?
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Massive haemorrhage: activate the protocol; the surgeon packs the liver. (Crisis)
Plasma, platelets and red cells 1:1:1; crystalloid kept to a minimum.
Tranexamic acid 1 g over 10 minutes, then 1 g over 8 hours; he's within 3 hours.
No permissive hypotension for his brain: noradrenaline 0.05–0.3 mcg/kg/min while blood runs in.
Warm everything and check ionised calcium; citrate lowers it.
Platelets if under 50 × 10⁹/L, or under 100 with diffuse oozing.
Crisis
After packing, his right pupil is fixed and dilated; BP 118/70. What do you do?
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A unilateral fixed pupil means uncal herniation: a neurological emergency. Crisis
Osmotherapy now: mannitol 0.25–1 g/kg over 10–15 minutes, or hypertonic saline.
Hyperventilate briefly as a bridge to surgery, not for long.
Raise the head of the bed 30 degrees, keep the neck straight, systolic 110 or above.
Urgent CT and neurosurgery; evacuation if a haematoma has grown. After surgery
ICP monitoring afterwards to steer his CPP.
Fatal mistakes
Permissive hypotension in his head injury.
Prolonged hyperventilation.
Hypotonic or glucose-containing fluids.
Checked against: Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition (2017) · Miller 10e · Stoelting 8e · Barash 9e
Mark Got it only if you said every point. Again brings the case back tomorrow; Got it brings it back in 3, then 7, 14 and 30 days.
Same topic, another patient
Run these after the main case when you have time. Same skills, a different patient or setting.
Another patient · ICU and trauma. Head injury with splenic bleeding for laparotomy. Same head injury with splenic bleed: pupil change before haemorrhage
Know this first
One systolic below 90 doubles mortality after severe head injury.
Systolic 110 or more for ages 15–49.
CPP 60–70 mmHg.
No routine hyperventilation; a short spell at PaCO2 30–35 bridges to definitive care.
Glucose 110–150 mg/dL, never above 180.
The patient
31-year-old man, 85 kg, after a car crash; GCS 9 (E2 V2 M5), right frontal contusions on CT, no mass needing surgery.
Splenic rupture with ongoing bleeding; FAST positive. 2 units of red cells given in the emergency department.
No regular drugs. Emergency laparotomy and splenectomy.
Vitals: BP 92/58, HR 124, SpO2 95% on oxygen, RR 22; pupils equal and reactive.
The examiner asks
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Consider
What are your considerations?
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A 31-year-old with a moderate-to-severe head injury and a bleeding spleen, for emergency laparotomy. Patient
As a trauma patient: xABCDE, and preventing secondary brain injury starts in the primary survey.
Two goals clash: low pressure suits the spleen, but his brain needs perfusion. Disease
A single systolic under 90 doubles his mortality.
So no permissive hypotension; the spleen must come out fast instead. Surgery
Prepare
What physiological targets will you aim for?
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Systolic 110 or more for his age. (Disease)
SpO2 above 95% and PaO2 80–120 mmHg.
CO2 normal at 35–38; no prophylactic hyperventilation.
Head up 30°, neck midline, collar loosened so his jugular veins drain.
Glucose 110–150 mg/dL, below 180; temperature normal.
Hb above 7 at the least; below 10 may slow his brain recovery.
Plan
How do you conduct the anaesthetic?
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Rapid sequence with in-line stabilisation; ketamine and rocuronium 1.2 mg/kg. Airway
Inside 3 hours of injury, so tranexamic acid 1 g, then 1 g over 8 hours; blood at 1:1:1. Disease
Noradrenaline holds his systolic while the surgeon controls the spleen.
PEEP is fine once he's filled; it won't raise his ICP.
Pupils checked regularly, since I've lost his GCS under anaesthesia.
Repeat CT after; ICP monitor if his GCS falls to 8 or less. After surgery
Crisis
Forty minutes in, his right pupil is 6 mm and unreactive; BP 104/60, HR 58. What do you do?
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Critical neuroworsening: a new unequal pupil means herniation until proven otherwise. Crisis
Tell the surgeon and call neurosurgery; head up, neck straight, deep enough to stop straining.
Hypertonic saline first because he is bleeding: it expands volume, while mannitol diuresis empties him.
Mannitol 0.25–1 g/kg over 10–15 minutes only once he is filled.
Short hyperventilation to PaCO2 30–35, as a bridge only.
Systolic held up; CPP target 60–70.
Urgent CT once the spleen is out; surgery if neurosurgery advises. After surgery
Crisis
As the spleen is mobilised, BP falls to 76/40 and HR rises to 140. What do you do?
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Haemorrhage with a head injury: his cerebral perfusion falls every minute this lasts. (Crisis)
Surgeon clamps the splenic pedicle; I give warmed blood fast.
Noradrenaline to bring his systolic back towards 110 while volume catches up.
Massive transfusion at 1:1:1, with calcium and fibrinogen checked.
No hypoxia now: hypotension together with hypoxia sharply raises his mortality.
Fatal mistakes
Accepting low pressures to limit bleeding when his brain is injured.
Prolonged hyperventilation.
Missing the signs of herniation.
Checked against: Miller 10e · Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition (2017) · Updated initial trauma management: key changes in ATLS (2026)