In a child with a traumatic extradural hematoma, repeated vomiting, decreased consciousness, and left‑sided weakness, should the immediate priority be emergent surgical evacuation of the hematoma or rapid‑sequence intubation with airway protection?

Immediate Management of Traumatic Extradural Hematoma with Focal Neurological Deficit

In this child with extradural hemorrhage, focal neurological deficit (left-sided weakness), and decreased consciousness, the immediate priority is rapid-sequence intubation with airway protection, followed immediately by emergent surgical evacuation of the hematoma. Both interventions are critical and must occur in rapid sequence, but airway control takes absolute precedence to prevent secondary brain injury during transport and surgery.

Airway Management Takes Priority

Secure the airway immediately through endotracheal intubation with mechanical ventilation before any other intervention. 1, 2, 3

• Airway control is the absolute first priority in severe traumatic brain injury, and pre-hospital tracheal intubation decreases mortality in trauma patients 1
• The American College of Surgeons recommends immediate airway control through endotracheal intubation before neurosurgical intervention 2
• Confirm correct tube placement through end-tidal CO₂ monitoring to maintain PaCO₂ within normal range, as hypocapnia induces cerebral vasoconstriction and risks brain ischemia 1
• The repeated vomiting and decreased consciousness (sleepiness) place this child at imminent risk for aspiration and airway compromise 1

Hemodynamic Stabilization During Intubation

• Maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine) without delay, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome 1, 2
• Avoid hypotensive sedative agents during intubation; use continuous infusions rather than boluses to prevent hemodynamic instability 1, 3
• Correct any hypovolemia, but do not delay vasopressor use while waiting for fluid resuscitation 1

Immediate Surgical Evacuation After Airway Secured

Once the airway is secured, proceed immediately to emergent surgical evacuation of the extradural hematoma. 4, 1

• The presence of focal neurological deficit (left-sided weakness) is an absolute indication for urgent neurosurgical intervention, as it indicates significant brain compression and mass effect 4
• Symptomatic extradural hematoma, regardless of location, requires immediate surgical evacuation 1, 4
• The American Association of Neurological Surgeons states that any extradural hematoma causing focal neurological signs necessitates immediate surgical treatment 4
• Delaying surgical intervention in symptomatic patients with extradural hematoma leads to neurological deterioration and worse outcomes 4

Why Both Are Essential in Sequence

The clinical presentation of repeated vomiting, decreased consciousness (sleepiness), and focal neurological deficit indicates:

• Increased intracranial pressure from the expanding hematoma causing mass effect 1
• Impending herniation evidenced by the focal weakness 4
• Compromised airway protection from decreased consciousness and vomiting 1

Critical pitfall to avoid: Never delay intubation to rush to surgery, as unprotected airway during transport or induction of anesthesia can cause aspiration, hypoxemia, or hypercarbia—all of which cause secondary brain injury and worsen outcomes 1, 2

Surgical Approach

The surgical intervention involves:

• Craniotomy for hematoma evacuation 4
• Control of bleeding source (typically middle meningeal artery) 4
• Assessment and management of any dural tear 4

Post-Operative Management

After surgery, this child will require:

• Intracranial pressure monitoring, as post-operative ICP monitoring is indicated given the preoperative focal neurological deficit and decreased consciousness 1
• Maintain cerebral perfusion pressure between 60-70 mmHg 1
• Continue mechanical ventilation with end-tidal CO₂ monitoring to maintain normocapnia 1
• Monitor for complications including rebleeding, infection, and persistent intracranial hypertension 4

Evidence Regarding Conservative Management Does Not Apply

While some studies describe conservative management of extradural hematomas 5, 6, these protocols explicitly exclude patients like this child who present with:

• Focal neurological deficits 5
• Decreased level of consciousness 5
• Active neurological deterioration (progressive symptoms) 6

Conservative management criteria require Glasgow Coma Scale 13-15, hematoma <40mm, and <6mm midline shift with no focal deficits 5—none of which apply to this symptomatic child with left-sided weakness.