A 61-year-old woman is admitted to the ICU with head trauma following an alcohol-induced fall down a flight of stairs. She is known to have moderately severe COPD, but is otherwise in relatively good health. Her admission CT scan of the head is normal. Five days after ICU admission, she has a Glasgow coma scale score of 10, with pupils 4 mm and reactive to light. She opens her eyes to voice, loud sounds, and pain, but makes only incomprehensible sounds. She localizes and withdraws purposefully to painful stimuli. No seizure activity has been observed, and an EEG shows only diffuse slow-wave activity. She is afebrile and remains extubated, and has a forceful spontaneous cough productive of mucoid phlegm. Her medications consist of occasional morphine for discomfort and nebulized albuterol and ipratropium bromide for COPD. While you are discussing her status and prognosis at the bedside with her husband, the nurse interrupts your conversation to tell you that the patient has a fixed and dilated pupil on the right side (Fig 1
). You immediately examine the patient, but apart from the dilated pupil, her physical examination remains unchanged. An urgent CT scan of the head shows no changes. The patient’s husband, a retired neurologist, is alarmed and asks what will be done next. What is the best course of action at this point?