Management of Stable Extradural Hematoma with Hypoactivity
This patient requires immediate neurosurgical consultation and urgent surgical evacuation of the extradural hematoma, not conservative observation. The presence of vomiting and hypoactivity following head trauma with confirmed extradural hematoma represents neurological deterioration that mandates surgical intervention.
Rationale for Surgical Evacuation
Surgical evacuation is indicated for symptomatic extradural hematoma regardless of current hemodynamic stability 1. The clinical presentation includes:
- Post-traumatic vomiting: This indicates increased intracranial pressure and potential ongoing expansion of the hematoma 2
- Hypoactivity/decreased responsiveness: This represents altered mental status and neurological impairment, which is a clear indication for surgery 1, 3
- "Stable but crying": This description suggests the patient is not neurologically normal despite vital sign stability 1
The key surgical indications present in this case are 1, 3:
- Symptomatic extradural hematoma with neurological changes (hypoactivity)
- Post-traumatic vomiting suggesting elevated intracranial pressure
- Evidence of clinical deterioration from baseline
Why Observation is Inappropriate Here
Conservative management of extradural hematoma is only appropriate when ALL of the following strict criteria are met 4:
- Glasgow Coma Scale score 13-15 with normal neurological examination
- Hematoma volume <40mm in maximum diameter
- Midline shift <6mm
- No other surgical lesions present
This patient fails the first criterion because hypoactivity and vomiting represent neurological impairment, not a normal examination 4. Even if the patient appears "stable" hemodynamically, the neurological symptoms indicate the hematoma is causing mass effect and requires evacuation 1.
Critical Pitfalls to Avoid
- Never delay surgical intervention while waiting for "further observation" when neurological symptoms are present 1. Extradural hematomas can expand rapidly, and the classic "lucid interval" followed by deterioration can progress to herniation and death 5
- Never rely solely on initial hemodynamic stability as an indicator for conservative management when neurological signs are present 1
- Never assume a single CT scan rules out progression - delayed expansion of extradural hematomas is well-documented, but this patient already has symptoms warranting surgery 5
Immediate Management Steps
Prior to surgical evacuation 1:
- Maintain systolic blood pressure >110 mmHg using vasopressors if needed (phenylephrine or norepinephrine)
- Ensure airway protection given altered mental status and vomiting
- Avoid hypotension, as even single episodes worsen neurological outcomes
- Transfer immediately to neurosurgical facility without delay for "stabilization"
The answer is B: surgical evacuation. Observation with repeat CT in 2 hours is inappropriate given the presence of neurological symptoms (vomiting and hypoactivity) that indicate the extradural hematoma is already causing clinically significant mass effect 1, 3, 4.