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

Immediate Surgical Consultation is Required

This pediatric patient with subdural hematoma, GCS 14, confusion, and focal neurologic deficit (left-sided weakness) requires immediate neurosurgical consultation (Option C), as this constellation of findings represents a neurosurgical emergency with approximately 23% risk of requiring operative intervention. 1

Why Surgical Consultation Takes Priority

Risk Stratification Confirms High-Risk Status

• GCS 14 automatically classifies this patient as high-risk in children ≥2 years old, regardless of other findings. 1
• The presence of altered mental status (confusion) further confirms high-risk status in pediatric subdural hematoma. 1
• Focal neurologic deficit (left-sided weakness) indicates significant intracranial pathology requiring immediate specialist evaluation. 1
• Patients with GCS 14 and focal deficits have significantly higher rates of requiring neurosurgical intervention compared to those with GCS 15. 1

Clinical Deterioration Risk

• Serial GCS assessments are critical, as deterioration from GCS 14 strongly predicts the need for surgical evacuation. 1
• Clinical deterioration can occur rapidly, and the window for optimal surgical intervention may be missed without immediate specialist involvement. 1
• A statistically significant decline in GCS score between initial assessment and hospital admission is predictive of the need for surgery in subdural hematoma patients. 2

Why Other Options Are Inappropriate

Hyperventilation (Option A) - Not First-Line

• Hyperventilation is a temporizing measure for impending herniation, not a definitive management strategy. 1
• This patient requires neurosurgical evaluation first; hyperventilation may be considered by the neurosurgical team if there are signs of herniation, but it is not the primary management decision at this point.

IV Mannitol (Option B) - Premature Without Neurosurgical Input

• While mannitol is indicated for reduction of intracranial pressure and brain mass 3, its use should be coordinated with neurosurgical consultation rather than administered independently.
• Mannitol carries significant risks including renal complications, fluid/electrolyte imbalances, and may increase cerebral blood flow and worsen intracranial hypertension in children during the first 24-48 hours post-injury. 3
• The decision to use medical management versus surgical evacuation requires neurosurgical expertise, particularly given this patient's focal deficits. 1

Follow with CT in 24 Hours (Option D) - Dangerous Delay

• Assuming GCS 14 represents "mild" head injury and delaying neurosurgical consultation is a critical pitfall to avoid. 1
• Patients with GCS 14 have approximately 23% risk of positive CT findings requiring intervention. 1
• The window for optimal surgical intervention may be missed with delayed imaging and consultation. 1
• While some pediatric subdural hematomas can be managed conservatively 4, 5, this decision requires immediate neurosurgical assessment, not delayed follow-up imaging.

Immediate Management Priorities While Awaiting Neurosurgery

• Maintain airway, breathing, and circulation with close monitoring. 1
• Perform serial GCS assessments to detect any deterioration. 1
• Avoid long-lasting sedatives and paralytic medications before neurosurgical evaluation, as these prevent detection of clinical deterioration. 2
• The neurosurgical team will determine whether surgical evacuation or conservative management with close monitoring is appropriate based on the complete clinical picture and imaging findings. 2

Critical Clinical Context

• Hematoma thickness >10 mm and midline shift >5 mm are strong predictors of need for surgical evacuation. 2
• However, even with smaller hematomas, clinical status (GCS and focal deficits) may dictate surgical intervention. 2
• In pediatric patients initially managed conservatively, 85% (11/13) developed chronic subdural hematomas requiring delayed intervention, emphasizing the need for expert neurosurgical guidance from the outset. 5