What is the management for a patient with a subdural hematoma, Glasgow Coma Scale (GCS) 14, left side weakness, and mild headache after an accident?

Management of 17-Year-Old with Subdural Hematoma, GCS 14, and Focal Weakness

This patient requires immediate admission for close neurological observation with serial assessments and repeat imaging, not discharge, immediate surgery, or prophylactic intubation (Option C). 1, 2

Rationale for Admission and Observation

The presence of a documented subdural hematoma on CT mandates admission regardless of GCS score, as delayed deterioration can occur even in patients who initially appear stable. 2 The combination of GCS 14, focal neurological deficit (left side weakness), and confirmed subdural hematoma places this patient in a category requiring intensive monitoring but not necessarily immediate surgical intervention. 1, 2

Why Not Discharge (Option A)

• Any patient with documented subdural hematoma on CT requires admission, as discharge is contraindicated even in those with normal examinations due to risk of delayed deterioration requiring neurosurgery. 2
• Serial GCS assessments provide substantially more valuable clinical information than a single determination, with declining scores indicating poorer prognosis. 2
• The original GCS validation studies demonstrated that approximately 13% of patients who became comatose had an initial GCS score of 15, illustrating the inadequacy of a single assessment. 3

Why Not Immediate Surgery (Option B)

• Patients with GCS ≥13 and subdural hematoma can be safely managed conservatively with close monitoring, particularly when neurologically stable without signs of herniation. 4, 5
• The critical surgical thresholds are hematoma thickness ≥10mm or midline shift ≥5mm combined with clinical deterioration, not the mere presence of subdural hematoma. 6, 4
• Recent evidence shows that 90% of patients with GCS ≥13 and acute subdural hematoma who don't require immediate evacuation can achieve independence (modified Rankin Scale 0-3) with conservative management initially. 7

Why Not Prophylactic ICU Intubation (Option D)

• ICU admission with intubation is premature for a patient with GCS 14 who can protect their airway, unless there is evidence of herniation or rapidly deteriorating neurological status. 2
• Long-acting sedatives or paralytics should not be administered before neurosurgical evaluation, as this masks clinical deterioration. 2

Specific Observation Protocol

Serial Neurological Monitoring

• Perform GCS monitoring every 15 minutes for the first 2 hours, then hourly for the following 12 hours. 2
• Document individual GCS components (Eye, Motor, Verbal) rather than just sum scores, as component profiles predict outcomes. 2
• Assess pupillary size and reactivity at each evaluation, as these are prognostic indicators. 2

Critical Thresholds for Intervention

• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning. 2
• Development of focal neurological deficits indicating mass effect necessitates surgical intervention. 2
• Clinical deterioration with GCS decline of ≥2 points requires neurosurgical evacuation. 2

Physiological Targets During Observation

• Maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion. 2
• Maintain oxygen saturation >95% to prevent hypoxemic secondary injury. 1, 2
• Correct confounding factors including sedating medications, alcohol, or metabolic derangements. 2

Observation Duration and Reassessment

• The observation period should be 24-72 hours with serial clinical assessments and repeat imaging. 2
• Failure to show neurological improvement within 72 hours is a negative prognostic factor requiring reassessment of management strategy. 2
• If the patient remains stable or improves during this period, continued conservative management is appropriate. 4, 5

Prognostic Factors Supporting Conservative Management

• Patients younger than 65 years with GCS >8 have functionally independent outcomes in 78-85% of cases with conservative management. 4
• Patients with subdural hematomas with thickness ≤10mm and midline shift ≤5mm show functionally independent outcomes in 82% of cases. 4
• When comparing radiographic parameters, maximum hemorrhage thickness and midline shift are the strongest independent risk factors for neurosurgical intervention within 48 hours. 6

Critical Pitfalls to Avoid

• Do not make irreversible decisions before 72 hours unless brain death criteria are met or there is clear clinical deterioration. 8
• Do not delay correction of secondary insults (hypotension, hypoxia) while waiting to observe. 8
• Avoid administering long-acting sedatives or paralytics that would mask neurological changes. 2
• Do not rely solely on initial GCS—the change in GCS from prehospital to admission assessment is predictive of need for surgery. 5