What is the most appropriate management for a child who fell from a tree, had a seizure, vomited, has clear head swelling, and is becoming somnolent?

Management of Pediatric Head Trauma with Seizure, Vomiting, and Altered Consciousness

The most appropriate management is B: Intubation and spine protection. This child requires immediate airway control before any other intervention, including hematoma evacuation. 1

Why Intubation Takes Absolute Priority

Airway management must be established before any surgical intervention, including hematoma evacuation. 1 This child presents with multiple indicators of compromised airway protection and increased intracranial pressure:

• Post-traumatic seizure indicates significant brain injury requiring immediate airway control and stabilization 1
• Vomiting in an obtunded patient creates immediate aspiration risk that can be fatal 1
• Progressive somnolence suggests decreased level of consciousness, meaning the child cannot protect their own airway 1
• Seizures compromise airway protective reflexes in pediatric head trauma patients 1

Critical Physiological Rationale

Hypoxemia and hypercarbia from inadequate airway management worsen intracranial pressure and brain injury in pediatric head trauma patients. 1 Without a secured airway:

• The child cannot be safely transported for CT imaging 1
• Any neurosurgical procedure, including hematoma evacuation, cannot be performed safely 1
• Risk of aspiration pneumonitis from vomiting is imminent 1
• Inability to control ventilation leads to secondary brain injury 1

Essential Intubation Technique Considerations

Maintain cervical spine immobilization throughout the entire intubation process, as all pediatric trauma patients must be assumed to have cervical spine injury until proven otherwise. 1 The mechanism (fall from tree) and neurological findings mandate spine precautions. 1

Control ventilation with end-tidal CO2 monitoring during and after intubation, as both hypocapnia and hypercapnia adversely affect cerebral circulation. 1

Maintain systolic blood pressure >110 mmHg during intubation, as even a single episode of hypotension worsens neurological outcome in pediatric head trauma patients. 1

Post-Intubation Management Sequence

After securing the airway:

1. Obtain immediate CT scan without delay to identify surgical lesions 1
2. Maintain normocapnia and ensure adequate sedation to prevent ICP spikes 1
3. Transfer to a center with pediatric neurosurgical expertise if not already present 1
4. Hematoma evacuation becomes appropriate only after airway control is established and CT imaging confirms a surgical lesion requiring drainage 1

Why Hematoma Evacuation Alone is Incorrect

Attempting hematoma evacuation without first securing the airway would be catastrophic because:

• The patient cannot be safely anesthetized without airway control 1
• Vomiting during induction would cause aspiration 1
• Positioning for surgery is impossible without airway protection 1
• The surgical procedure itself requires controlled ventilation 1

Common pitfall: Rushing to neurosurgical intervention without establishing basic life support priorities. The ABCs of trauma resuscitation always begin with airway evaluation, and effective airway management is imperative before any definitive treatment. 2