In a child with a traumatic extradural hematoma presenting with vomiting, somnolence, and left‑side weakness, should the airway be secured first (intubation) or should emergent hematoma evacuation be performed?

Immediate Airway Management: Intubate First

In a child with extradural hemorrhage presenting with repeated vomiting, somnolence, and focal neurological deficit (left-side weakness), immediate endotracheal intubation must be performed before any surgical intervention, including hematoma evacuation. The airway takes absolute priority in this clinical scenario.

Why Intubation Must Come First

Aspiration Risk is Immediate and Life-Threatening

• In children with head trauma who are drowsy and vomiting, the risk of aspiration is immediate and severe, making endotracheal intubation the first lifesaving intervention before any surgical or imaging procedure 1
• The combination of altered consciousness and active vomiting creates a catastrophic aspiration risk that supersedes even urgent neurosurgical needs 1

GCS Score Mandates Airway Protection

• While the exact GCS is not stated, the clinical picture of somnolence with focal weakness strongly suggests GCS ≤8, which is an absolute indication for immediate intubation 1, 2
• Patients with GCS ≤8 should be intubated without delay to protect the airway, prevent secondary brain injury from hypoxemia or hypotension, and ensure adequate ventilation 1
• Even brief episodes of hypoxemia (occurring in ~20% of traumatic brain injury patients) are linked to higher mortality and poorer neurological recovery 1

Surgical Timing Depends on Airway Security

• Hematoma evacuation or any operative management should only be undertaken after the airway has been definitively secured and the patient is hemodynamically stable, to prevent catastrophic loss of airway control during surgery 1
• The most critical pitfall is delaying intubation to obtain imaging or proceed directly to surgery; airway management takes absolute priority 1, 2

Rapid Sequence Intubation Protocol

Preparation Phase

• Prepare vasoactive agents (ephedrine, metaraminol, noradrenaline) in advance to counteract induction-related hypotension 1
• Have video laryngoscopy immediately available as first-line technique, as trauma patients frequently present with difficult airways 1, 2
• Use rapid-onset muscle relaxants (rocuronium or succinylcholine) for paralysis 3, 1

Cervical Spine Protection

• Apply manual in-line stabilization during intubation rather than leaving the cervical collar in place, which can impede laryngoscopic view 1, 2

Hemodynamic Targets During Intubation

• Maintain systolic blood pressure >110 mmHg and mean arterial pressure ≥80 mmHg throughout the peri-intubation period 1
• The combination of hypotension and hypoxemia carries an estimated 75% mortality rate in traumatic brain injury 1

Post-Intubation Ventilation Management

Oxygenation Goals

• Target arterial PaO₂ ≥13 kPa (≈98 mmHg) while avoiding prolonged hyperoxia 1
• Confirm correct tracheal tube placement with waveform capnography immediately after insertion 1, 2

Carbon Dioxide Control

• Aim for normocapnia with PaCO₂ 4.5–5.0 kPa (34–38 mmHg) 1
• Avoid routine hyperventilation, which induces cerebral vasoconstriction and aggravates ischemic injury; use only as brief rescue for impending herniation 1

Timing of Hematoma Evacuation

After Airway is Secured

• Once intubated and hemodynamically stable, proceed immediately to hematoma evacuation 1
• Early surgical intervention in pediatric extradural hematoma produces excellent results, with maximum mortality occurring in patients operated >24 hours after injury 4
• Best motor response at presentation and time between injury to surgery are critical factors determining outcome 4

Common Pitfalls to Avoid

• Never proceed directly to surgery without securing the airway first – losing the airway during hematoma evacuation would be catastrophic 1
• Never tolerate systolic BP <110 mmHg during or after intubation, as this significantly worsens neurological outcomes 1
• Never delay intubation for CT scanning – the airway must be secured before any imaging or surgical intervention 1
• Avoid blind finger sweeps in a vomiting child, as this can displace material into the larynx and worsen obstruction 1

Pediatric-Specific Considerations

• Pediatric airway management has higher difficulty rates compared to adults; intubations should be performed by clinicians with specific pediatric airway experience 1
• Use cuffed endotracheal tubes with cuff pressure maintained ≤20 cm H₂O 3, 5
• Have supraglottic airway devices immediately available as rescue if intubation fails 3, 2