Traumatic Brain Injury, Emergency Decompressive Craniectomy, and Secondary Insult Prevention — WACS Viva & Clinical Scenarios (Neuroanaesthesia)

Exam-style traumatic brain injury, emergency decompressive craniectomy, and secondary insult prevention viva scenarios with examiner probes and model answers…

Scenarios covered

• SCENARIO 1: A 24-year-old commercial motorcyclist (not wearing a helmet) is brought to the emergency department 2 hours after a road traffic crash. His GCS is 6 (E1V2M3), right pupil is 6 mm and unreactive, left pupil is 3 mm and reactive. Blood pressure is 168/92 mmHg, heart rate 56 bpm, and SpO₂ 91% on room air. Non-contrast cranial CT demonstrates a 20 mm thick acute right extradural haematoma with severe uncal herniation. Formulate your anaesthetic management from emergency airway control through to operative resuscitation.
• SCENARIO 2: A 32-year-old male with severe TBI and an acute left subdural haematoma is undergoing an emergency decompressive craniectomy. Concurrently, he has blunt abdominal trauma with suspected splenic laceration. His blood pressure is 82/45 mmHg and heart rate is 128 bpm. Detail your choice of induction agents, resuscitation fluids, vasopressors, and hemodynamic endpoints balancing systemic hypovolaemia against secondary brain ischaemia.
• SCENARIO 3: During an emergency decompressive hemicraniectomy for a 28-year-old female with an acute subdural haematoma, the neurosurgeon relieves the bone flap and incises the dura. Immediately upon dural opening, the underlying brain swells violently through the craniectomy defect, turning dusky and tense. Formulate your systematic emergency management plan for this acute intraoperative crisis.
• SCENARIO 4: A 45-year-old polytrauma patient with severe TBI (initial GCS 5) is admitted to the Intensive Care Unit following decompressive craniectomy. Over the first 24 hours, the patient demonstrates refractory intracranial hypertension (ICP consistently >25 mmHg despite first-tier medical measures). Outline your escalation through tier-two and tier-three neuro-intensive care strategies.