What is the best management for a patient with an epidural hematoma, left-sided weakness, and a history of trauma, as shown on a computed tomography (CT) scan?

Best Management for Epidural Hematoma with Neurological Deterioration

In a patient with epidural hematoma presenting with altered consciousness (sleepiness), vomiting, and focal neurological deficit (left-sided weakness), the best immediate management is airway protection through intubation (Option B), followed by urgent hematoma evacuation.

Algorithmic Approach to Management

Step 1: Immediate Airway Assessment and Stabilization

• Secure the airway first if GCS ≤8 or signs of increased intracranial pressure are present 1
• This patient's sleepiness and vomiting indicate decreased level of consciousness and risk of aspiration, making airway protection the immediate priority before any other intervention 1
• Declining Glasgow Coma Scale motor score is the most sensitive indicator of worsening, and altered consciousness with vomiting represents imminent risk of aspiration 2

Step 2: Hemodynamic Targets During Resuscitation

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions 3, 4
• These targets must be achieved while securing the airway and preparing for definitive treatment 3

Step 3: Urgent Neurosurgical Intervention

• After airway control is established, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention 3
• The presence of focal weakness (left-sided) indicates significant mass effect requiring evacuation 3, 1
• New or worsening anisocoria signals impending herniation and mandates immediate surgical decompression 2

Why Each Option Ranks as It Does

Why Intubation (B) Takes Priority Over Hematoma Evacuation (A):

• You cannot safely evacuate a hematoma in a patient who cannot protect their airway 1
• The patient's vomiting with altered consciousness creates immediate aspiration risk that supersedes even urgent surgical needs 1
• Maintaining adequate oxygenation (PaO2 60-100 mmHg) and ventilation (PaCO2 35-40 mmHg) during interventions is mandatory 4

Why Observation (C) is Inappropriate:

• This patient has both clinical deterioration (sleepiness, vomiting) and focal neurological deficit (left-sided weakness), which are absolute contraindications to conservative management 5
• Conservative management is only appropriate for small, asymptomatic epidural hematomas without neurological deficits 5
• 32% of initially asymptomatic patients with small epidural hematomas eventually require evacuation, and this patient is already symptomatic 5

Why MRI (D) is Wrong:

• MRI has no role in acute epidural hematoma management 3
• CT scan has already confirmed the diagnosis; MRI would only delay life-saving intervention 3
• Transfer times to diagnostic imaging must be carefully considered in hemodynamically unstable patients 3

Critical Pitfalls to Avoid

• Never delay airway protection in a vomiting patient with altered consciousness, even for "urgent" neurosurgery 1
• Never assume a patient with focal neurological deficits can be managed conservatively, regardless of hematoma size 5
• Failing to maintain cerebral perfusion pressure 60-70 mmHg after securing the airway leads to worse outcomes 2, 4
• Delaying neuroimaging or neurosurgical consultation in patients with post-traumatic neurological deterioration is associated with preventable mortality 1

Post-Intervention Monitoring

After airway control and hematoma evacuation:

• ICP monitoring is strongly indicated given the preoperative altered consciousness and focal deficit 3, 4
• Serial neurological examinations every 4 hours minimum 2
• Maintain cerebral perfusion pressure 60-70 mmHg (avoid >70 mmHg due to risk of vasogenic edema) 2, 4
• 30-40% of hematomas expand in the first 12-36 hours, requiring vigilant monitoring 2

The correct answer is B (intubation), but this must be immediately followed by A (hematoma evacuation) once the airway is secured.