What is the next best step for a patient who fell from a tree, presenting with drowsiness and sleepiness, and has a computed tomography (CT) brain scan showing a concave-shaped lesion consistent with a subdural hematoma?

Immediate Airway Management is the Priority

In a patient with altered mental status (drowsy and sleepy) following significant trauma, the next best step is to intubate and secure the airway (Option B) before proceeding with neurosurgical evaluation or any other intervention.

Clinical Reasoning

Airway Takes Precedence Over Everything

• A drowsy, sleepy patient with traumatic brain injury has a compromised level of consciousness that places them at immediate risk for airway compromise, aspiration, and inability to protect their airway 1
• The Glasgow Coma Scale (GCS) appears to be significantly depressed based on the description of "drowsy and sleepy," which typically indicates a GCS ≤13, meeting criteria for moderate traumatic brain injury 1
• Patients with decreased level of consciousness from intracranial pathology require immediate airway protection before any other intervention, including neurosurgical consultation 1, 2

Why Not Neurosurgical Evaluation First (Option A)

While neurosurgical evaluation is absolutely necessary and urgent for subdural hematoma, it cannot occur before airway stabilization:

• A patient who cannot protect their airway may deteriorate rapidly during transport to neurosurgery or during evaluation, leading to aspiration, hypoxia, and secondary brain injury 1, 2
• Maintaining adequate oxygenation and ventilation is critical to prevent secondary brain injury in traumatic brain injury patients 1, 2
• Hypotension and hypoxia during the evaluation period dramatically worsen outcomes in traumatic brain injury 2

The Subdural Hematoma Context

• The CT finding of a "concave shaped lesion" is consistent with subdural hematoma (crescentic collection that crosses suture lines) 3, 4
• Subdural hematomas with altered mental status require urgent neurosurgical evaluation, but only after the airway is secured 3, 2
• The mechanism (fall from tree) combined with altered consciousness suggests significant force and high risk for ongoing deterioration 1

Why Not Repeat CT in 6 Hours (Option C)

• A patient with altered mental status and confirmed intracranial hemorrhage requires immediate intervention, not watchful waiting 1, 2
• Repeat CT at 24 hours is appropriate for stable patients with small subdural hematomas and normal neurological examination, but this patient is symptomatic with decreased consciousness 1, 5
• Delaying definitive management in a patient with compromised consciousness risks catastrophic deterioration 1, 2

Correct Management Sequence

1. Secure the airway immediately through rapid sequence intubation given the altered mental status 1, 2
2. Maintain systolic blood pressure >100 mmHg and mean arterial pressure 80-110 mmHg to ensure adequate cerebral perfusion pressure 1, 2
3. Obtain immediate neurosurgical consultation once the airway is secured 3, 2
4. Check anticoagulant/antiplatelet use and reverse if present 3, 2, 4
5. Prepare for potential surgical evacuation if the subdural hematoma is >10 mm thick or causes midline shift >5 mm 2, 5

Critical Pitfalls to Avoid

• Never delay airway management to obtain specialty consultation in a patient with altered consciousness 1, 2
• Do not assume the patient will remain stable during evaluation—traumatic brain injury patients can deteriorate rapidly 1
• Avoid hypotension and hypoxia at all costs, as these cause secondary brain injury and worsen outcomes 1, 2
• Do not rely on clinical examination alone to determine urgency—altered mental status with confirmed intracranial hemorrhage is an emergency 1, 2