What is the most appropriate immediate management for a child who fell from a tree and now has head swelling, vomiting, and progressive drowsiness?

Management of Pediatric Head Trauma with Progressive Drowsiness

Intubation is the most appropriate immediate management for this child with progressive drowsiness following head trauma. 1, 2

Immediate Airway Management Priority

Children who remain unconscious (Glasgow Coma Score ≤8) or have features suggestive of raised intracranial pressure warrant elective intubation and ventilation. 1 Progressive drowsiness in the context of head trauma with vomiting represents deteriorating neurological status and impending loss of airway protective reflexes, making airway security the immediate priority. 1, 3

Why Intubation Takes Precedence

• Airway protection is paramount in children with altered consciousness, as they cannot maintain airway patency or protect against aspiration, particularly with ongoing vomiting. 1, 3

• Progressive drowsiness indicates evolving intracranial pathology (likely epidural or subdural hematoma given the mechanism and head swelling), which will continue to worsen without definitive management. 2, 3

• Controlled ventilation prevents secondary brain injury by maintaining optimal oxygenation and preventing hypercapnia, which can exacerbate intracranial pressure. 1, 4

• All patients with Glasgow Coma Scale ≤8 must be treated with endotracheal intubation and controlled ventilation under continuous monitoring. 4

Why Not Hematoma Evacuation First

While this child likely has an expanding intracranial hematoma requiring surgical evacuation, you cannot safely transport or operate on a child with a compromised airway and deteriorating consciousness. 1, 3

• Securing the airway must precede any diagnostic imaging or surgical intervention. 3, 4

• Cerebral perfusion depends on adequate oxygenation and blood pressure, both of which require a secured airway in an obtunded patient. 1, 4

• Attempting hematoma evacuation without airway control risks catastrophic aspiration, hypoxia, and cardiovascular collapse during transport or induction of anesthesia. 4

Clinical Algorithm

1. Immediate intubation using rapid sequence induction with cervical spine precautions (jaw thrust without head tilt). 1, 3, 4

2. Controlled ventilation targeting normal PaCO₂ (avoid hyperventilation unless signs of herniation). 1

3. Urgent non-contrast CT to identify the intracranial injury once airway is secured. 2

4. Neurosurgical consultation for definitive hematoma evacuation if indicated. 2

Critical Pitfalls to Avoid

• Never delay airway management to obtain imaging first in a child with deteriorating consciousness—the airway always comes first in the ABCDE sequence. 3

• Do not assume the child will stabilize—progressive drowsiness after head trauma represents ongoing intracranial bleeding until proven otherwise. 2

• Avoid rapid rises in PaCO₂ during initiation of ventilation, as this can worsen intracranial pressure. 1