What is the best course of treatment for a patient with a subdural hematoma, mild hypertension (elevated blood pressure), and a Glasgow Coma Scale (GCS) score of 13 in the Emergency Department (ED)?

Emergency Department Management of Subdural Hematoma with GCS 13 and Mild Hypertension

This patient requires urgent neurosurgical consultation, CT imaging, close neurological monitoring, and blood pressure control to systolic 110-150 mmHg, but does NOT require immediate intubation given the GCS of 13.

Immediate Airway Assessment

• Do not intubate this patient based on GCS alone – the threshold for intubation in traumatic brain injury is GCS ≤8, and this patient has a GCS of 13 1, 2, 3
• However, prepare for potential intubation if the patient shows deteriorating consciousness (fall in GCS of ≥2 points or motor score of ≥1 point), loss of protective airway reflexes, or signs of impending herniation 1, 2
• Serial GCS assessments every 15-30 minutes are critical, as approximately 13% of patients who become comatose initially present with GCS 15, and deterioration can be rapid 1

Blood Pressure Management

Target systolic blood pressure 110-150 mmHg and mean arterial pressure >90 mmHg 1. This represents a critical balance:

• Maintain SBP >110 mmHg to ensure adequate cerebral perfusion pressure and prevent secondary brain injury 1
• Keep SBP <150 mmHg if within 6 hours of symptom onset and immediate surgery is not planned, to reduce risk of hematoma expansion 1
• The patient's current BP of 150/100 is at the upper acceptable limit and requires careful titration downward

Practical approach to BP control:

• Use short-acting titratable agents such as labetalol or nicardipine that allow rapid adjustment 1
• Avoid aggressive BP reduction that could compromise cerebral perfusion
• Recent evidence suggests no mortality difference between maintaining SBP 100-150 versus <180 in traumatic subdural hematoma, but tighter control (110-150) is preferred by consensus guidelines 4, 1

Urgent Diagnostic Evaluation

• Obtain non-contrast head CT immediately to characterize the subdural hematoma, assess for midline shift, and identify any life-threatening mass effect 1
• Perform full neurological examination including pupillary assessment and motor score 1, 2
• The presence of subdural hematoma with GCS 13 places this patient at significant risk – studies show 3-8% of patients with GCS 13-15 require neurosurgery 1

Neurosurgical Consultation

• Contact neurosurgery urgently – all patients with traumatic subdural hematoma and altered mental status (GCS <15) require neurosurgical evaluation 1
• Surgical intervention is indicated if there is significant mass effect, midline shift, or clinical deterioration 1
• Even without immediate surgical indication, these patients require ICU-level monitoring given the risk of deterioration 1

Monitoring and Supportive Care

Maintain optimal physiological parameters:

• PaO₂ ≥13 kPa (approximately 98 mmHg) – supplemental oxygen as needed 1
• PaCO₂ 4.5-5.0 kPa (34-38 mmHg) – avoid both hypercarbia and excessive hyperventilation 1
• Avoid hyperventilation unless there are signs of impending uncal herniation 1
• Position head of bed at 30 degrees to facilitate venous drainage (while maintaining cervical spine precautions if trauma mechanism warrants) 1

Prepare medications for potential deterioration:

• Have rapid sequence intubation medications ready: high-dose fentanyl (3-5 µg/kg), induction agent (propofol or ketamine if hemodynamically unstable), and neuromuscular blockade (rocuronium 1 mg/kg or succinylcholine 1.5 mg/kg) 1
• Prepare osmotic therapy (mannitol 20% or hypertonic saline) for emergency use if signs of herniation develop 1
• Have vasoactive medications available (ephedrine, metaraminol, noradrenaline, labetalol) 1

Critical Pitfalls to Avoid

• Do not discharge this patient – even with GCS 13, subdural hematoma requires admission and serial neurological assessments, as deterioration can occur hours to days after initial presentation 1
• Do not delay CT imaging – clinical examination alone cannot reliably predict which patients have surgical lesions 1
• Do not aggressively lower blood pressure below 110 mmHg systolic – this risks secondary brain injury from hypoperfusion 1
• Do not assume stability – the combination of subdural hematoma and hypertension increases risk of hematoma expansion, particularly if the hypertensive crisis contributed to spontaneous bleeding 5, 6
• Do not rely on a single GCS measurement – serial assessments are essential, as the original validation studies of GCS showed that single measurements have limited prognostic value in mild TBI 1

Disposition

• Admit to ICU or step-down unit with neurosurgical consultation 1
• If neurosurgical capabilities are not available at your facility, arrange urgent transfer with appropriate monitoring and medications during transport 1
• Ensure continuous monitoring of vital signs, neurological status, and maintain target blood pressure throughout transfer 1