Exploratory laparotomy after a motorcycle crash with brain injury

A 24-year-old man, 78 kg and 178 cm, was riding a motorcycle that struck a car at highway speed 45 minutes ago. He was helmeted. His Glasgow Coma Scale score was 13 at the scene and is now 8: eyes open to pain, incomprehensible sounds, and he localizes to pain. His right pupil is 5 mm and sluggish; the left is 3 mm and brisk. He vomited once in the ambulance. He arrives in a rigid cervical collar with a traction splint on a deformed right thigh. The FAST examination shows free fluid around the spleen and in the pelvis, and the trauma surgeon is taking him straight to the operating room for exploratory laparotomy. A head CT has not been obtained. Paramedics gave 1 L of lactated Ringer's solution.

He is otherwise healthy, takes no medications and has no known drug allergies. Friends say he ate dinner about three hours before the crash.

• Blood pressure 86/48 mmHg, heart rate 128, respiratory rate 26, SpO2 92% on a non-rebreather mask, temperature 35.6 °C
• Access: two 18-gauge peripheral IVs
• Hemoglobin 9.8 g/dL, platelets 168,000/µL, INR 1.5, fibrinogen 160 mg/dL
• Arterial blood gas: pH 7.24, PaCO2 34 mmHg, PaO2 72 mmHg, base deficit 9 mmol/L, lactate 5.8 mmol/L
• Ionized calcium 1.04 mmol/L, potassium 4.1 mEq/L, glucose 182 mg/dL
• Chest radiograph: right fourth to sixth rib fractures, no pneumothorax
• Femur radiograph: comminuted right midshaft femur fracture
• Cervical spine: not imaged and not cleared