Question 1 · Emergency medicine and critical care, Clinical
A 30-year-old man with a severe closed head injury is intubated in the emergency department while transfer to neurosurgery is arranged. He lies flat, a rigid collar is fastened tightly, and the tube tie is knotted firmly around his neck. Blood pressure, oxygen saturation, and PaCO2 (40 mm Hg) are normal, but his pupils have become sluggish. Which simple measure should be taken first?
- A. Lay him flat with his legs raised to support blood flow
- B. Dexamethasone to reduce swelling around the injury
- C. Remove the collar completely to free the neck veins
- D. Head-up tilt of 30 degrees, neck midline, ties loosened
- E. Hyperventilate to a PaCO2 of 25 mm Hg until transfer
Show the answer and explanation
Answer: D. Head-up tilt of 30 degrees, neck midline, ties loosened
He has signs of rising intracranial pressure while lying flat with tight circumferential compression of the neck. Raising the head of the bed to about 30 degrees and keeping the head midline improves cerebral venous drainage; tight tube ties or a collar that compresses the jugular veins should be loosened. The collar stays on until the spine is cleared, but it is adjusted so it does not compress the neck veins. These are the first, simplest steps while definitive neurosurgical care is arranged.
Why the other options are wrong
- A. Lay him flat with his legs raised to support blood flow: Lying flat or head-down impedes cerebral venous drainage and raises intracranial pressure; his blood pressure is already normal.
- B. Dexamethasone to reduce swelling around the injury: Corticosteroids do not help traumatic brain swelling and are not used in head injury.
- C. Remove the collar completely to free the neck veins: His cervical spine is not cleared; the collar should be loosened or adjusted, not removed.
- E. Hyperventilate to a PaCO2 of 25 mm Hg until transfer: Deep hypocapnia constricts cerebral vessels and risks ischaemia; prophylactic hyperventilation is no longer recommended.
Key point: In raised intracranial pressure, first raise the head of the bed to about 30 degrees, keep the head midline, and remove anything compressing the neck veins, while definitive care is arranged.
References
- Traumatic brain injury (TBI), MSD Manual Professional Edition
- Diagnosis and management of elevated intracranial pressure in the emergency department (2023), International Journal of Emergency Medicine (PMC10571389)