What is the appropriate management for a pediatric patient presenting with a subdural hematoma, confusion, left-sided weakness, and a Glasgow Coma Scale (GCS) score of 14?

Management of Pediatric Subdural Hematoma with GCS 14

Immediate surgical consultation is the appropriate management for this pediatric patient with subdural hematoma, confusion, left-sided weakness, and GCS 14. This patient meets high-risk criteria requiring urgent neurosurgical evaluation and likely operative intervention.

Risk Stratification

This patient falls into the high-risk category based on established pediatric head trauma criteria:

• GCS of 14 automatically classifies as high risk in children 2 years or older, regardless of other findings 1
• The presence of altered mental status (confusion) further confirms high-risk status 1
• Focal neurologic deficit (left-sided weakness) indicates significant intracranial pathology requiring immediate specialist evaluation 1

Immediate Management Priorities

Surgical consultation should be obtained immediately while initiating supportive measures:

• Contact neurosurgery urgently for evaluation and operative planning 2, 3
• Maintain airway, breathing, and circulation with close monitoring 1
• Avoid long-acting sedatives or paralytics that could mask neurological deterioration 2
• Serial GCS assessments are critical, as deterioration from GCS 14 strongly predicts need for surgical evacuation 1, 2

Surgical Decision-Making

The decision between operative and conservative management depends on specific parameters:

• Hematoma thickness >10mm or midline shift >5mm typically requires surgical evacuation 2
• Patients with GCS 14 and focal deficits have significantly higher rates of requiring neurosurgical intervention compared to those with GCS 15 1, 4
• Clinical deterioration between initial assessment and hospital admission strongly predicts need for surgery (mean GCS drop from 8.4 to 6.7 in surgical candidates) 2
• Conservative management may be considered only if: hematoma is small (<10mm thickness, <5mm shift), patient remains neurologically stable, and close ICU monitoring with serial imaging is available 2, 3

Role of Adjunctive Measures

Hyperventilation and IV mannitol are temporizing measures only, not definitive management:

• These interventions may be used to control elevated intracranial pressure while preparing for surgery, but do not replace surgical consultation 5
• ICP control is critical to outcome, but the primary brain injury and mass effect from the hematoma dictate the need for evacuation 5
• Do not delay surgical consultation to administer medical therapies in a patient with focal deficits and GCS 14 2, 5

Why Observation Alone is Inappropriate

Following with CT in 24 hours without surgical consultation is dangerous in this clinical scenario:

• Patients with GCS 14 have approximately 23% risk of positive CT findings requiring intervention 1
• Delayed recognition and treatment of subdural hematoma significantly worsens outcomes in pediatric patients 6, 3
• Clinical deterioration can occur rapidly, and the window for optimal surgical intervention may be missed 1, 2
• Conservative management is only appropriate for highly selected cases with smaller hematomas, stable neurological status, and immediate neurosurgical availability 2, 3

Expected Outcomes

With appropriate surgical management:

• Overall mortality for pediatric subdural hematoma is approximately 11% with modern treatment protocols 3
• Good recovery rates of 53-67% can be achieved with timely surgical intervention in appropriate cases 6, 3
• Functional outcomes are significantly better when surgery is performed before further neurological deterioration occurs 2, 5
• Factors predicting worse outcome include: age extremes, lower admission GCS, and postoperative ICP >45 mmHg 5

Critical Pitfall to Avoid

The most dangerous error is assuming GCS 14 represents "mild" head injury and delaying neurosurgical consultation. While technically in the "mild TBI" range (GCS 13-15), a GCS of 14 with focal deficits and confirmed subdural hematoma represents a neurosurgical emergency requiring immediate specialist evaluation 1. The presence of focal weakness indicates significant mass effect or underlying brain injury that may require urgent surgical decompression 2, 3.