Surgical Evacuation is Required
This patient requires urgent surgical evacuation of the extradural hematoma, not observation. 1
Why Surgery is Mandatory in This Case
The presence of altered mental status (hypoactivity) is an absolute indication for surgery in extradural hematoma, regardless of hematoma size. 1 The combination of vomiting and hypoactivity indicates increased intracranial pressure requiring immediate intervention. 1
Critical Time-Sensitive Factors
- Target for surgical evacuation is within 4 hours of injury, as earlier evacuation directly correlates with better outcomes 1
- The American College of Surgeons classifies this as a time-critical condition requiring immediate transfer to a neurosurgical center 1
- Even though the patient appears "stable," extradural hematomas can expand rapidly and delayed treatment worsens prognosis 1
Why Observation is Contraindicated
Delaying surgery to "observe" a symptomatic patient is explicitly advised against by the American College of Emergency Physicians, as it worsens prognosis. 1 The key distinction here is that this patient is symptomatic (vomiting, hypoactive) rather than asymptomatic.
When Conservative Management Would Be Appropriate (Not This Case)
Conservative management is only appropriate for patients who meet ALL of the following criteria:
- Glasgow Coma Scale 13-15 (fully conscious, not hypoactive) 2, 3
- Hematoma volume <30-40 cm³ 2, 3
- Midline shift <5-6 mm 2, 3
- No neurological symptoms or deficits 3
This patient fails the consciousness criterion by being hypoactive and symptomatic with vomiting.
Immediate Pre-Operative Actions Required
While arranging urgent surgery:
- Maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine) immediately if needed 1, 4
- Secure the airway if Glasgow Coma Scale deteriorates below 9 or if unable to protect airway 1
- Avoid delaying transfer for "stabilization" at a facility without neurosurgery 4
Common Pitfall to Avoid
Do not use repeat CT scans as a management strategy in symptomatic patients, as this delays definitive treatment. 1 Repeat imaging is only appropriate for asymptomatic patients being managed conservatively with close observation. 2, 5