Immediate Surgical Evacuation is Required
This patient requires emergency craniotomy for hematoma evacuation immediately after airway protection via rapid-sequence intubation. 1, 2
Rationale for Immediate Surgical Intervention
This 12-year-old presents with an absolute indication for urgent neurosurgical decompression: an acute epidural hematoma with midline shift, accompanied by deteriorating neurological status (loss of consciousness, repeated vomiting, somnolence, focal weakness, and lateralizing signs). 1, 2
Emergency surgical evacuation of symptomatic extradural hematoma is mandatory irrespective of location. 1, 2 The presence of:
- Midline shift (indicating significant mass effect) 1
- Focal neurological deficit (left limb weakness) 1, 2
- Altered consciousness with vomiting 2
- Lateralizing signs 1
These findings collectively represent rapid neurological decline requiring immediate decompression. 1
Critical Timing Consideration
Every minute of delay in decompression increases the risk of transtentorial herniation and brain-stem death; this is a neurosurgical emergency. 1 Emergency surgical evacuation reduces mortality from approximately 80% to 27% and increases independent functional outcome from 20% to 53%. 1 Shorter time from injury to surgical evacuation is directly associated with better neurological outcomes. 1
Correct Sequence: Airway FIRST, Then Surgery
Before proceeding to the operating room, the airway must be secured via rapid-sequence endotracheal intubation with mechanical ventilation. 2 This patient has:
- Repeated vomiting (high aspiration risk) 2
- Altered consciousness/somnolence (inability to protect airway) 2
- Likely GCS ≤8 based on clinical description 2
Delaying intubation to rush to surgery can cause aspiration, hypoxemia, or hypercarbia, which worsen neurological outcomes; therefore intubation must precede surgical evacuation. 2
During intubation, maintain systolic blood pressure >110 mmHg using vasopressors (phenylephrine or norepinephrine), as even a single episode of SBP <90 mmHg markedly worsens neurological outcomes. 2 End-tidal CO₂ monitoring must confirm tube placement and maintain PaCO₂ at 35-40 mmHg to avoid cerebral vasoconstriction. 2
Why Other Options Are Incorrect
Option C (Admit and observe) is contraindicated. Conservative management is only appropriate for asymptomatic patients with small EDH (<40mm), minimal midline shift (<6mm), and GCS 13-15. 3, 4 This patient has symptomatic EDH with midline shift, neurological deterioration, and focal deficits—all absolute contraindications to observation. 1, 2
Option D (Repeat CT after 12 hours) is dangerous and inappropriate. This patient is already demonstrating clinical deterioration with mass effect on imaging. Waiting 12 hours risks irreversible herniation and death. 1 Repeat imaging is only indicated for stable, asymptomatic patients being managed conservatively. 3
Option B alone (Intubate and secure airway) is incomplete. While airway protection is the immediate first step, it is not the definitive management. 2 The airway must be secured as preparation for emergency craniotomy, not as standalone treatment. The mass lesion causing brain compression requires surgical evacuation. 1, 2
Post-Operative Management
After hematoma evacuation:
- Intracranial pressure monitoring is mandatory given the pre-operative altered consciousness and focal deficits 2
- Maintain cerebral perfusion pressure 60-70 mmHg 2
- Continue mechanical ventilation with normocapnia 2
Common Pitfall to Avoid
Do not delay surgery for "stabilization" beyond securing the airway and achieving hemodynamic targets. 2 High-dose corticosteroids have no role in traumatic brain injury management and should not be administered. 1 External ventricular drains are ineffective and unsafe as primary treatment for mass lesions; they are only indicated post-operatively if hydrocephalus develops. 1