Clinical Picture

Step 1: Primary Survey (ATLS approach)

• A – Airway with C-spine protection: apply a cervical collar/manual immobilization until the spine is cleared, especially given the fall mechanism
• B – Breathing: check respiratory rate, SpO2, give oxygen if needed
• C – Circulation: pulse, BP, look for and control any external bleeding (scalp lacerations can bleed heavily)
• D – Disability:
  • GCS (eye/verbal/motor breakdown, not just the total)
  • Pupil size and reactivity — a sluggish, dilated pupil can indicate uncal herniation and third nerve compression from raised ICP
  • Bedside blood glucose immediately — hypoglycemia is a dangerous, easily reversible cause of "unconsciousness" and must be excluded early
• E – Exposure: look for other injuries from the fall

Step 2: Focused History (crucial in this case)

• Exact sequence: did she feel dizzy/faint and then fall, or fall first and then lose consciousness? (points toward syncope vs. traumatic LOC)
• Any palpitations, chest pain, or prodrome before the fall (cardiac syncope)
• Any tongue bite, incontinence, post-ictal confusion (seizure)
• Preceding standing/posture change, dehydration, missed meals (vasovagal/orthostatic)
• Medication history — anticoagulants/antiplatelets are critical, as they lower the threshold for imaging even with minor head injury
• Menstrual/pregnancy history in a woman of childbearing age

Step 3: Investigations

• Continuous vitals monitoring — BP, HR, RR, SpO2, temperature
• ECG to screen for arrhythmia as a cause of syncope
• CT head (non-contrast) — indicated here because of the witnessed LOC after a fall; standard (NICE-type) adult criteria for urgent CT head include GCS <15 at any point, LOC or amnesia with a dangerous mechanism, more than one vomiting episode, post-traumatic seizure, focal neurological deficit, or signs of a basal skull fracture (CSF oto/rhinorrhoea, Battle's sign, raccoon eyes) — all of which should be actively looked for on exam
• C-spine imaging if there is neck tenderness or a high-risk mechanism
• Blood glucose, CBC, electrolytes; consider orthostatic BP measurements once stable

Step 4: About the BP (155/90 mmHg)

Step 5: Ongoing Management

• Neuro-observations (GCS, pupils, vitals) every 15-30 minutes initially
• Keep nil by mouth until assessed, IV access, analgesia, antiemetic if vomiting
• If CT is normal, GCS is 15, and no red flags remain, she can be observed for a period and discharged with head-injury advice (return if worsening headache, vomiting, drowsiness, or seizures) and safety-net advice for syncope work-up as an outpatient (echo, Holter if cardiac cause suspected)
• If CT is abnormal (contusion, hemorrhage, fracture) or GCS deteriorates, urgent neurosurgical referral is required
• Bailey and Love's Short Practice of Surgery, 28th Edition, p. 380 (Primary survey, GCS, pupils, medical management of head injury)

Key Point: Don't Rush to Lower This BP

Why

• This degree of BP elevation after a head injury is usually the sympatho-adrenal stress response to trauma, pain, and anxiety. Per Adams and Victor's Principles of Neurology: "Within hours after head injury, the sympatho-adrenal response and elevation of blood pressure recedes spontaneously... unless the blood pressure elevation is extreme (greater than 180/95 mm Hg), it can [be left untreated]" - Adams and Victor's Principles of Neurology, 12th Ed.
• Blood pressure supports cerebral perfusion pressure (CPP = MAP - ICP). If there is any element of raised intracranial pressure from the fall (even subclinical), the body raises systemic BP reflexively to keep the brain perfused. Dropping BP artificially at this point can worsen cerebral perfusion and secondary brain injury.
• Tintinalli's Emergency Medicine explicitly warns: "permissive hypotension worsens outcome in patients with brain injury" and that even a "normal range" BP can be inadequate if ICP is raised.
• Brain Trauma Foundation guidance (cited in Morgan and Mikhail's Clinical Anesthesiology) targets CPP of 50-70 mmHg and ICP <20 mmHg, not a specific "normal" systemic BP - the goal is perfusion, not a number on a chart.

What To Actually Do for "Stabilizing" BP

1. Treat the cause of the sympathetic surge, not the number: adequate analgesia, calm reassurance, correct hypoxia/hypercapnia - these often normalize BP on their own.
2. Serial monitoring, not single-reading reaction: recheck BP after analgesia and settling; trend it alongside HR and respiratory pattern.
3. Watch specifically for Cushing's triad (hypertension + bradycardia + irregular respiration) - if this develops, it signals critically raised ICP and is a neurosurgical emergency requiring urgent CT and ICP-directed measures (head elevation, hyperosmolar therapy, hyperventilation as a temporizing measure, neurosurgical intervention) - not antihypertensive drugs.
4. Correct hypovolemia if present rather than assuming the BP itself needs treating - isolated head injury rarely causes hypotension, so if BP were low, look for another bleeding source first.
5. Only consider pharmacologic BP control if it is truly extreme (>180/95-200 systolic sustained) or there's evidence of a hypertensive emergency unrelated to the head injury (e.g., pre-existing malignant hypertension, encephalopathy). In that scenario, use a short-acting, titratable IV agent such as labetalol or nicardipine, which lower BP smoothly without causing sharp CPP drops - and this should be done in consultation with neurosurgery, after CT head, not empirically at triage.

• Adams and Victor's Principles of Neurology, 12th Ed. - Management of Raised Intracranial Pressure
• Tintinalli's Emergency Medicine, A Comprehensive Study Guide - Circulation/Head Injury sections
• Morgan and Mikhail's Clinical Anesthesiology, 7e - Key Concepts (CPP/ICP targets)