Immediate Airway Securement and Surgical Evacuation for Pediatric Extradural Hematoma
In a child with extradural hematoma presenting with decreased consciousness (sleepiness), focal neurological deficit (left-sided weakness), and signs of increased intracranial pressure (recurrent vomiting), the immediate priority is to secure the airway via rapid-sequence intubation while simultaneously preparing for urgent surgical evacuation of the hematoma—both interventions must occur emergently and in parallel, not sequentially. 1
Critical First Steps: Airway Management
Intubate immediately if the child shows any signs of decreased consciousness or neurological deterioration. The presence of recurrent vomiting combined with altered mental status creates high aspiration risk and indicates inability to protect the airway. 2
- Secure the airway with cervical spine precautions given the mechanism of injury (2-meter fall). 3
- Maintain systolic blood pressure above 110 mmHg during intubation to ensure adequate cerebral perfusion, as even brief hypotension worsens outcomes in brain-injured patients. 1
- Consider osmotic therapy (mannitol or hypertonic saline) if signs of herniation develop during preparation for surgery. 1
Definitive Treatment: Urgent Surgical Evacuation
The presence of focal neurological deficit (left-sided weakness) is an absolute indication for immediate neurosurgical intervention—this is non-negotiable. 1
- Focal neurological signs indicate significant brain compression and mass effect requiring craniotomy for hematoma evacuation. 1
- The American College of Surgeons and Neurocritical Care Society state that any extradural hematoma causing focal neurological signs necessitates immediate surgical treatment. 1
- Surgery should occur within 4 hours of injury when possible, as earlier evacuation correlates with better outcomes. 3
Why Both Interventions Are Essential
The child's clinical presentation demands simultaneous management:
- Sleepiness indicates decreased level of consciousness, which in the context of extradural hematoma signals impending herniation. 1
- Recurrent vomiting reflects increased intracranial pressure and creates aspiration risk. 4
- Left-sided weakness confirms that the hematoma is causing significant mass effect and brain compression requiring surgical decompression. 1
Delaying surgical intervention in symptomatic patients with extradural hematoma leads to neurological deterioration and worse outcomes. 1
Common Pitfalls to Avoid
- Never delay surgery to "stabilize" the patient medically—the hematoma itself is causing the instability, and only evacuation will reverse the process. 1
- Do not assume conservative management is appropriate even if the child is not deeply comatose—the presence of focal deficit makes this a surgical emergency regardless of GCS score. 1, 5
- Conservative management is only appropriate for patients with GCS 13-15, no focal deficits, hematoma <30-40 cm³, <15mm thickness, and <5-6mm midline shift. 6, 5 This child fails these criteria due to focal weakness and decreased consciousness.
- Intubation without surgical planning is inadequate—airway protection alone does not address the underlying mass effect. 1
Post-Operative Monitoring
After hematoma evacuation, the child requires:
- ICU monitoring with consideration for intracranial pressure monitoring. 7
- Maintenance of cerebral perfusion pressure between 50-70 mmHg. 7, 2
- Surveillance for complications including rebleeding, seizures, and infection. 7, 1
The answer is both interventions urgently: intubate to protect the airway while simultaneously mobilizing for immediate surgical evacuation, as the focal neurological deficit makes surgery the only definitive life-saving treatment. 1