20yrs old male driving a car involved in a highway MVC with Truck on .Patient groaning at scene.Scene to ED transport via ambulance about half n hour.Intubated and mechanically ventilated uppon arrival to emergency following ATLS. O/e - Pupils - Left 6mm NRTL,Right 4mm SRTL,GCS - E1V1M3-4.How to proceed with this case??

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CT shows bilateral basifrontal contusions, a contusion in midbrain with cerebral edema and multiple craniofacial fractures Pt probably has DAI too. No surgically evacuable lesion in Conservative management as per trauma protocol of TBI

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Bifrontal contusion, small interhemispheric blood, # nasal bones, brain edema bilaterally Air bubbles in the orbital, nasal& soft tissue. Suggest active supportive management as per trauma protocol. No neurosurgical intervention.at present .Consultation ENT , ophthalmology

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Contusions seen in bifrontal area and brain stem # frontal bone Diffuse cerebral edema Multiple facial bones # Conservative line of management as of now Consultations needed: Neurosurgery and Faciomaxillary

Agreed with sanjay sir ...recent trauma guideline 2017 ...managment of severe traumatic brain injury ..include 1.treatment 2 monitoring cerebral perfusion ..icp monitoring ...maintain blood pressure ...cvp monitoring.. ...icp threshhold etc ... repeat scan to be done to rule out ... aggravating cerebral edema or post traumatic infarct..

The first thing to do in this pt is to deal with herniation evident by unequal pupil. All other things should wait. Lpwering head end by 15 to 30 degree, midline nursing, 100 % FiO2, ABG, Mechanical ventilation to keep pCO2 between 30 to 35, analgesia, sedation and if needed paralysis by non-depolarising agents like vecuronium, and needed supportive management should be the order of intervention....@Dr. Shweta Malhotra @Rishi Bhatnager @Dr. Naveen Kesarwani
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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Bifrontal contusion RT>>Lt ... With interhemispheric haemorrhage with DAI. patient needs to be managed conservatively at the moment. Start Mannitol, Antiepileptics and repeat CT. and follow.....

Thank to all experts.

Check BP HR O2 Saturation IV fluids matched packed cell transfusion CT Brain plain 1hrly vitals Monitoring.

Le fort fracture requiring wiring.Nasal bone which is impact require deimpactio with Acsep forceps either immediate/intacranial edema subsides.Late repair may be difficult

CT Brain plain Antiepileptics Neurophysiology consultation

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