Logan, a 5-year-old boy, was riding his bike with his 7-year-old brother when he was struck from behind by a car traveling at approximately 40 mph. The driver indicated that she did not see the riders until she hit Logan, who was not wearing a helmet at the time of the accident. Logan was thrown from his bike and was found at the side of the road, unresponsive and posturing. Although he was uninjured, Logan’s brother witnessed the incident.

Emergency medical services arrived and placed Logan on a backboard with a c-collar. Because he was not protecting his airway, he was intubated and then given sodium chloride fluids and brought to the pediatric emergency department. Upon arrival, his Glasgow Coma Scale score was 5, and his right pupil was 6 mm and not reactive.

Logan’s initial head computed tomographic scan showed diffuse brain edema, with early downward transtentorial brain herniation. The pediatric neurosurgeon determined that no operative management was appropriate for Logan. Besides a small laceration on his forehead, Logan had no other injuries. At this time, he was taking a few spontaneous respirations and had occasional posturing of his extremities.

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