What is the proper action for a child with a subdural (subdural hematoma) hematoma from a car accident requiring urgent surgical exploration when all family members are present except the father, who is on the way to the hospital?

Management of Pediatric Subdural Hematoma Requiring Urgent Surgical Intervention

In the case of a child with subdural hematoma from a car accident requiring urgent surgical exploration, you should proceed with the surgery without consent as it is a life-saving procedure (option D).

Rationale for Proceeding Without Consent

The decision to proceed without consent in this scenario is based on several key factors:

1. Life-threatening nature of subdural hematoma: Subdural hematoma is a medical emergency that requires prompt neurosurgical intervention 1. Delays in treatment can lead to increased intracranial pressure, brain herniation, and death.

2. Consensus guidelines support immediate intervention: The World Journal of Emergency Surgery guidelines state with 100% agreement that "all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention" 2. This recommendation emphasizes the time-critical nature of neurosurgical interventions for traumatic brain injuries.

3. Acute subdural hematoma as a time-critical condition: Acute subdural hematoma is specifically identified as a condition requiring time-critical transfer and intervention 2. Waiting for parental consent could result in dangerous delays.

Clinical Decision Algorithm

1. Assess urgency and risk:

   • Confirm the diagnosis of subdural hematoma requiring urgent evacuation
   • Evaluate the patient's neurological status (GCS, pupils, focal deficits)
   • Determine if delay would increase risk of mortality or permanent neurological damage

2. Attempt expedited consent if possible:

   • If the father can be reached by phone quickly, inform him of the situation
   • However, do not delay surgery waiting for this communication

3. Document decision-making process:

   • Record the clinical urgency requiring immediate intervention
   • Document attempts to contact parents/guardians
   • Note the presence of other family members who were informed

4. Proceed with life-saving intervention:

   • Initiate surgical evacuation of the subdural hematoma
   • Maintain appropriate hemodynamic targets during surgery (SBP >100 mmHg or MAP >80 mmHg) 2

Important Considerations

• Neurosurgical emergencies take precedence: The American Association of Neurological Surgeons emphasizes that recognition of neurosurgical emergencies requiring immediate intervention is vital 3.

• Secondary brain injury prevention: Delaying surgery increases the risk of secondary brain injury. Maintaining adequate cerebral perfusion pressure is crucial in neurosurgical patients 3.

• Post-operative care: After the emergency surgery, ensure comprehensive communication with the father upon his arrival, explaining the situation, the procedure performed, and the medical necessity that required proceeding without formal consent.

Common Pitfalls to Avoid

• Unnecessary delay: Waiting for formal consent in a life-threatening situation can lead to irreversible neurological damage or death.

• Inadequate documentation: Failing to document the decision-making process and attempts to contact parents can create legal complications.

• Neglecting family communication: While proceeding with emergency surgery, ensure other family members present are informed about the situation and the medical necessity of immediate intervention.

The principle of acting in the best interest of the patient takes precedence in emergency situations where delay could result in death or permanent disability. This approach is consistent with medical ethics and emergency care standards worldwide.