In a child with a head injury after falling from a tree, presenting with vomiting, scalp swelling, and progressive drowsiness, what is the most appropriate immediate management?

Management of Pediatric Head Injury with Progressive Drowsiness

Intubation is the most appropriate immediate management for this child with severe traumatic brain injury presenting with vomiting, scalp swelling, and progressive drowsiness, as these signs indicate deteriorating consciousness requiring immediate airway protection and controlled ventilation. 1, 2

Immediate Airway Management Priority

The child requires immediate endotracheal intubation based on the following critical indicators:

• Progressive drowsiness represents altered mental status and declining Glasgow Coma Scale (GCS), which is a high-risk criterion for severe traumatic brain injury requiring immediate airway control 1
• Children with GCS ≤8 and signs of deteriorating consciousness require immediate endotracheal intubation to prevent hypoxia and maintain controlled ventilation 2
• Vomiting combined with altered consciousness creates significant aspiration risk and indicates increased intracranial pressure 1, 3
• Airway control is the absolute priority in severe traumatic brain injury, and pre-hospital/emergency department tracheal intubation decreases mortality in trauma patients 1

Why Intubation Takes Precedence Over Hematoma Evacuation

Intubation must be performed before any consideration of surgical intervention:

• Controlled ventilation with end-tidal CO2 monitoring is essential to maintain PaCO2 between 4.5-5.0 kPa, as hypocapnia causes cerebral vasoconstriction and worsens brain ischemia 1, 2
• Maintaining PaO2 ≥13 kPa ensures adequate cerebral oxygenation and prevents secondary brain injury 2
• Hypoxemia (SaO2 <90%) combined with hypotension results in 75% mortality in traumatic brain injury 4
• Securing the airway allows safe transport for CT imaging to determine if surgical evacuation is actually needed 1

Clinical Context Supporting This Decision

The presentation strongly suggests severe traumatic brain injury with increased intracranial pressure:

• Vomiting is a significant predictor of intracranial injury, with recurrent vomiting increasing the odds ratio to 2.3 for intracranial injury 3
• Scalp swelling (hematoma) combined with altered mental status has an odds ratio of 2.78 for intracranial injury 5
• Progressive drowsiness indicates evolving herniation syndrome, where the brainstem becomes compressed, compromising vital cardioregulatory centers 4
• Loss of consciousness or altered mental status combined with other high-risk features mandates immediate intervention 1, 6

Subsequent Management After Intubation

Once the airway is secured, the following steps should occur:

• Maintain systolic blood pressure >110 mmHg and mean arterial pressure ≥90 mmHg to ensure adequate cerebral perfusion pressure 1, 2
• Activate emergency medical services for immediate transport to a facility with neurosurgical capabilities 1
• Obtain non-contrast CT head using pediatric-specific protocols to identify intracranial hemorrhage, skull fractures, and mass effect 6
• Administer 0.9% normal saline exclusively, avoiding hypotonic solutions like Ringer's lactate which worsen cerebral edema 2

When Hematoma Evacuation Becomes Indicated

Surgical evacuation is indicated only after imaging confirms specific criteria:

• Symptomatic extradural hematoma regardless of location 1
• Acute subdural hematoma with thickness >5 mm and midline shift >5 mm 1
• External ventricular drainage for persistent intracranial hypertension despite medical management 1
• However, none of these surgical decisions can be made safely without first securing the airway and obtaining imaging 1, 2

Critical Pitfalls to Avoid

Common errors that increase mortality in this scenario:

• Delaying intubation while "observing" a deteriorating child increases mortality risk dramatically 2
• Allowing hypotensive episodes (systolic BP <90 mmHg for >5 minutes) significantly increases neurological morbidity and mortality 4
• Prophylactic hyperventilation should be avoided as it causes cerebral vasoconstriction and worsens outcomes 1, 2
• Attempting surgical intervention without airway control and hemodynamic stabilization is inappropriate 2