Surgical Evacuation is Indicated
This patient requires urgent surgical evacuation of the extradural hematoma, not observation. The presence of altered mental status (hypoactivity) combined with vomiting after head trauma represents a time-critical neurosurgical emergency requiring immediate intervention 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 combination of:
- Post-traumatic vomiting (indicating elevated intracranial pressure) 1
- Hypoactivity (altered mental status) 1
- Confirmed extradural hematoma on CT 1
creates a clinical picture that demands immediate surgical evacuation, not observation 1.
Critical Time Window
Target surgical evacuation within 4 hours of injury, as earlier intervention directly correlates with better neurological outcomes and survival 1. Emergency surgical intervention should occur before further neurological deterioration develops 2.
The Fatal Pitfall of "Observe and Repeat CT"
Do not delay surgery to "observe" a symptomatic patient - this is explicitly warned against as it worsens prognosis 1. Extradural hematomas can expand rapidly, and delayed diagnosis/treatment significantly increases mortality 1, 3.
Repeat CT scans should not be used as a management strategy in symptomatic patients because it delays definitive treatment 1. While delayed extradural hematomas can occur 3, using serial imaging as primary management in an already symptomatic patient is inappropriate 1.
When Conservative Management Would Be Appropriate (Not This Case)
Conservative management is only suitable for patients who meet ALL of the following criteria 4, 5:
- Glasgow Coma Scale 13-15 with normal mental status (not hypoactive) 4
- Hematoma volume <40mm 4
- Midline shift <6mm 4
- No neurological deterioration 5
- Neurological signs that are static or improving 5
Your patient fails these criteria due to hypoactivity and vomiting, making conservative management dangerous 1.
Immediate Pre-Surgical Actions Required
While arranging urgent neurosurgical transfer 1:
- Maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine) if needed 1
- Prepare for airway management if Glasgow Coma Scale deteriorates below 9 or airway protection becomes compromised 1
- Avoid delays - this is a time-critical condition requiring immediate transfer to a neurosurgical center 1
Mortality Context
Extradural hematoma carries approximately 5% mortality with prompt surgical intervention 2, 6. However, all deaths in one prospective series were attributed to avoidable delays in management 6. Zero mortality is achievable with prompt referral and immediate surgical access 6.