In a child who fell from a height, is vomiting, has scalp swelling, and is now drowsy, what is the most appropriate immediate management: endotracheal intubation or hematoma evacuation?

Immediate Intubation is the Most Appropriate Management

In a child who has fallen from a tree and is now drowsy with vomiting and head swelling, endotracheal intubation takes absolute priority over hematoma evacuation. The child's drowsiness indicates altered consciousness (likely GCS ≤8), which mandates immediate airway protection before any surgical intervention 1, 2.

Why Intubation Must Come First

Airway Protection is the Absolute Priority

• The American College of Surgeons states that securing the airway takes absolute priority in trauma patients with altered consciousness 1
• A drowsy child after head trauma cannot protect their airway and is at imminent risk of aspiration, especially given the active vomiting 2
• The sequence must be: secure airway → control bleeding/evacuate hematoma → resuscitate 2
• Attempting hematoma evacuation before securing the airway risks catastrophic loss of airway control during the procedure 2

GCS ≤8 is a Mandatory Indication for Intubation

• Standard of care across all trauma and critical care guidelines mandates intubation when GCS ≤8 2
• "Drowsy" in a pediatric head trauma patient with vomiting and scalp swelling strongly suggests GCS ≤8, indicating severe impairment of consciousness 2
• Deteriorating consciousness after head trauma requires immediate airway intervention without delay 2

The Danger of Delaying Intubation

• Hypoxia from airway obstruction or aspiration will cause cerebral ischemia and cardiac arrest within 5-6 minutes 3
• Delaying intubation to perform CT scanning or surgical procedures in patients with GCS ≤8 is explicitly not recommended 2
• Vomiting in an obtunded child creates immediate aspiration risk that cannot be managed without a secured airway 4, 1

Proper Intubation Technique for This Child

Rapid Sequence Intubation is the Gold Standard

• Rapid sequence induction with endotracheal intubation via the oral route is the gold standard for pediatric trauma airway management 1, 5
• Manual in-line stabilization should be applied during intubation given the fall mechanism (potential cervical spine injury) 1
• Videolaryngoscopy should be used as first-line if available and the operator is experienced 1

Critical Hemodynamic Management During Intubation

• Maintain systolic blood pressure >110 mmHg and mean arterial pressure >90 mmHg during the peri-intubation period 2
• Prepare vasoactive medications (ephedrine, metaraminol, noradrenaline) before induction 2
• Avoid hyperventilation except as a brief life-saving measure for impending herniation 2

Post-Intubation Priorities

• Confirm correct tube placement using waveform capnography immediately 2, 6
• Maintain normocapnia (PaCO₂ 35-40 mmHg) and adequate oxygenation (PaO₂ ≥13 kPa) 1, 2
• Secure the tube with self-adhesive tape rather than circumferential ties to avoid impairing venous drainage 2

When to Evacuate the Hematoma

Only After Airway is Secured

• Hematoma evacuation is performed after the airway is definitively secured and the patient is stabilized 1, 2
• The child must be intubated, adequately oxygenated, and hemodynamically stable before any surgical intervention 4, 1
• Attempting surgery on a drowsy, vomiting child without airway control is medically indefensible 1, 2

Common Pitfalls to Avoid

• Never delay intubation to obtain imaging in a child with GCS ≤8 - secure the airway first, then image 2
• Do not assume the child can protect their airway because they are "only drowsy" - drowsiness after head trauma indicates severe impairment 2
• Avoid the temptation to rush to hematoma evacuation - losing the airway during surgery is catastrophic 2
• Do not perform blind finger sweeps if vomiting causes airway obstruction - this can impact foreign material in the larynx 4
• Ensure experienced personnel perform the intubation - pediatric airways have higher rates of difficulty 4