Surgical Evacuation is Indicated
This patient requires urgent surgical evacuation of the extradural hematoma, not observation. The presence of altered mental status (hypoactivity) and vomiting following head trauma with a confirmed extradural hematoma on CT scan are absolute indications for immediate neurosurgical intervention, regardless of current hemodynamic stability 1.
Why Surgery is Mandatory in This Case
Altered consciousness is an absolute indication for surgery in extradural hematoma patients, regardless of hematoma size 1. The clinical presentation described—vomiting and hypoactivity—indicates:
- Increased intracranial pressure: Vomiting signals elevated ICP requiring immediate intervention 1
- Neurological deterioration: Hypoactivity represents altered mental status, which mandates urgent surgical evacuation 1
- Time-critical condition: This requires immediate transfer to a neurosurgical center 1
Critical Timing
The target for surgical evacuation is within 4 hours of injury, as earlier evacuation directly correlates with better outcomes 1. Extradural hematomas are potentially lethal lesions with emergency surgical intervention appropriate before further neurological signs appear 2.
Why Observation is Inappropriate Here
Delaying surgery to "observe" a symptomatic patient worsens prognosis, as extradural hematomas can expand rapidly 1. The option to observe and repeat CT in 2 hours is contraindicated because:
- Repeat CT scans should not be used as a management strategy in symptomatic patients, as it delays definitive treatment 1
- Delayed extradural hematomas can develop even after initially normal scans, and neurologic impairment necessitates immediate surgical intervention 3
- Standard neurosurgical management demands prompt evacuation of all symptomatic extradural hematomas to obtain low mortality and morbidity 4
Conservative Management is Only for Asymptomatic Patients
Conservative management is reserved for a highly select group that does not match this patient's presentation 5, 6:
- Glasgow Coma Scale 13-15 with no altered consciousness
- Hematoma volume <40 mm with <6 mm midline shift
- Static or improving neurological status (not deteriorating)
- No vomiting or other signs of increased ICP
This patient fails these criteria due to hypoactivity and vomiting 6.
Immediate Pre-operative Actions
While arranging urgent surgery 1:
- Maintain systolic blood pressure above 110 mmHg using vasopressors (phenylephrine or norepinephrine) to prevent hypotension and worsening neurological outcome 1
- Secure the airway if Glasgow Coma Scale deteriorates below 9 or if unable to protect airway 1
- Avoid delays in transfer to neurosurgical center 1
Key Pitfall to Avoid
The most dangerous error would be choosing observation based on the patient being "stable" hemodynamically. Hemodynamic stability does not negate the need for surgery when neurological symptoms are present 1. The crying and hypoactivity represent symptomatic intracranial pathology requiring immediate surgical decompression, not serial imaging 1, 3.