What is the best management for a pediatric patient who fell from 2 meters, now presenting with vomiting, sleepiness, left-sided weakness, and a computed tomography (CT) scan showing an extradural hemorrhage?

Management of Pediatric Extradural Hemorrhage with Neurological Deterioration

This child requires immediate airway control through endotracheal intubation followed by urgent neurosurgical evacuation of the extradural hematoma.

Immediate Airway Management (Priority #1)

The presence of multiple episodes of vomiting and decreased level of consciousness (sleepiness) in a child with traumatic brain injury mandates immediate airway protection 1, 2. Intubation must be performed emergently before any other intervention, including surgery 1, 2.

• Establish airway control through endotracheal intubation and mechanical ventilation as the absolute priority, beginning immediately 2, 3
• Confirm correct tracheal tube placement through continuous end-tidal CO2 monitoring 1, 2
• Maintain PaCO2 within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia 1, 3

Hemodynamic Stabilization (Concurrent with Airway)

Maintain systolic blood pressure >100-110 mmHg using immediate vasopressor support 1, 2.

• Even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1, 2, 3
• Use vasopressors (phenylephrine or norepinephrine) immediately rather than waiting for fluid resuscitation, as fluids have delayed hemodynamic effects 1, 2, 3
• Avoid hypotensive sedative agents during intubation; use continuous infusions rather than boluses to prevent hemodynamic instability 2, 3

Urgent Neurosurgical Evacuation (Priority #2)

After airway control is established, this child requires immediate surgical evacuation of the extradural hematoma 1, 4, 3.

The presence of left-sided weakness indicates significant mass effect and neurological compromise, which are absolute indications for surgery 1, 4. The clinical deterioration (vomiting, decreased consciousness, focal neurological deficit) supersedes any consideration of conservative management 1.

Surgical Indications Present in This Case:

• Symptomatic extradural hematoma with focal neurological deficit (left-sided weakness) 4, 3
• Decreased level of consciousness with vomiting suggesting increased intracranial pressure 1
• Clinical deterioration from initial presentation 1

Why Conservative Management is NOT Appropriate Here:

Conservative management of extradural hematoma is only considered for patients meeting ALL of the following criteria 5, 6, 7:

• Glasgow Coma Scale 13-15 (fully conscious and coherent) 5, 6
• Hematoma volume <30-40 cm³ 5, 6, 7
• Hematoma thickness <10-15 mm 5, 7, 8
• Midline shift <5-6 mm 5, 6, 7
• No focal neurological deficits 5, 6
• No clinical deterioration 6

This child fails multiple criteria: he has decreased consciousness (sleepy), focal neurological deficit (left-sided weakness), and ongoing clinical deterioration (multiple episodes of vomiting) 1, 5, 6.

Intraoperative Considerations

• Administer mannitol (0.25-2 g/kg for adults; 1-2 g/kg for pediatric patients) as 15-25% solution over 30-60 minutes if signs of herniation develop 9
• Consider hypertonic saline (23.4% sodium chloride) for acute neurological deterioration with signs of herniation 1
• Maintain systolic blood pressure >100 mmHg during surgery; lower values may be briefly tolerated only if absolutely necessary for bleeding control 1

Post-Operative Management

• Implement intracranial pressure monitoring to detect intracranial hypertension and guide pressure-directed therapy 2, 3
• Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes 2, 3
• Implement detection and prevention strategies for post-traumatic seizures 2, 3
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal function 2, 3

Critical Pitfalls to Avoid

• Never delay intubation to "observe" a deteriorating patient with vomiting and decreased consciousness 1, 2
• Never attempt surgical evacuation without first securing the airway in a patient with decreased consciousness 1, 2, 3
• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors 2, 3
• Never consider conservative management in a patient with focal neurological deficits and clinical deterioration 1, 5, 6
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 2, 3