What is the most appropriate management for a young child with a head injury, seizure, vomiting, and decreased level of consciousness after falling from a tree?

Immediate Management: Intubation and Spine Protection

In a young child with post-traumatic seizure, vomiting, head swelling, and decreased consciousness after a fall from height, the most appropriate immediate management is intubation with spine protection (Option B), followed by urgent neurosurgical evaluation and CT imaging. This child presents with severe traumatic brain injury requiring immediate airway control and cervical spine precautions before any other interventions. 1, 2, 3

Why This is a Neurosurgical Emergency Requiring Immediate Airway Management

This clinical presentation represents severe traumatic brain injury with multiple high-risk features that mandate aggressive resuscitation:

• Post-traumatic seizure with altered mental status automatically classifies this as a high-risk severe head trauma requiring EMS activation and immediate hospital evaluation 1, 2
• Decreased level of consciousness ("sleepy") indicates potential increased intracranial pressure or evolving intracranial hemorrhage 2, 4
• Vomiting after head trauma is a high-risk feature for clinically important brain injury 2, 5
• Visible head swelling suggests significant impact force and possible skull fracture or underlying hematoma 2, 5
• Fall from height (tree) represents a severe mechanism of injury 5

Critical First Priority: Airway Control with Intubation

Tracheal intubation must be performed immediately in this child before any other interventions, including hematoma evacuation:

• Pre-hospital or emergency department intubation decreases mortality in severe pediatric traumatic brain injury patients 1, 3
• Children with severe head injury (implied GCS ≤8 based on seizure and decreased consciousness) requiring intubation have improved survival with early airway control compared to delayed intubation 3, 6
• Airway control is the absolute priority before neurosurgical intervention, as it allows control of ventilation to maintain normocapnia (PaCO₂ 35-40 mmHg) and prevent secondary brain injury from hypoxia or hypercapnia 1
• End-tidal CO₂ monitoring must be initiated during intubation to maintain appropriate ventilation, as hypocapnia causes cerebral vasoconstriction and brain ischemia 1

Simultaneous Spine Protection is Mandatory

Cervical spine precautions must be maintained throughout resuscitation:

• The mechanism (fall from tree) and presence of severe head injury create high risk for cervical spine injury 1
• Spine protection should be maintained during intubation and all patient movement until cervical spine injury is excluded by imaging 1, 2

Why Hematoma Evacuation Cannot Be First

Hematoma evacuation (Option A) is premature and dangerous without prior airway control:

• While this child likely has an intracranial hematoma requiring surgical evacuation (post-traumatic seizures carry 90.9% incidence of intracranial hematomas, with 81.8% requiring evacuation) 7, neurosurgery cannot proceed safely without a secured airway
• Urgent CT imaging must be obtained first to identify the specific lesion and guide neurosurgical decision-making 1, 2
• The sequence must be: (1) Intubation with spine protection, (2) Maintain systolic BP >110 mmHg, (3) Urgent CT head and cervical spine, (4) Neurosurgical consultation, (5) Hematoma evacuation if indicated 1, 2

Additional Critical Management Steps After Intubation

Once the airway is secured and spine protected:

• Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion—hypotension dramatically worsens neurological outcome 1
• Obtain urgent CT scan without delay to identify surgical lesions (epidural hematoma, subdural hematoma, depressed skull fracture) 1, 2
• Immediate neurosurgical consultation for likely surgical intervention given the high-risk presentation 2, 7
• Consider ICP monitoring if GCS ≤8 with abnormal CT findings, targeting ICP <20 mmHg 1, 2

Common Pitfalls to Avoid

• Never delay intubation to "observe" the child or obtain imaging first—airway control precedes all other interventions in severe TBI 1, 3
• Never assume the decreased consciousness is solely from the seizure—until CT excludes a mass lesion, any altered mental status must be attributed to potential intracranial hemorrhage 7
• Never allow hypotension even transiently, as a single episode of systolic BP <90 mmHg (or <110 mmHg in recent data) markedly worsens outcome 1
• Do not give anything by mouth to a child with decreased responsiveness after seizure, as aspiration risk is high 1