In a 6‑year‑old child who fell and now has drowsiness, nausea, vomiting, a Glasgow Coma Scale above 8, and a crescent‑shaped acute subdural hematoma on CT, what is the most appropriate immediate management?

Management of Pediatric Acute Subdural Hematoma with Deteriorating Consciousness

In a 6-year-old child with acute subdural hematoma and deteriorating consciousness (drowsiness, vomiting, decreased GCS >8), the immediate priority is to intubate and secure the airway, followed by urgent neurosurgical consultation for hematoma evacuation. 1

Immediate Airway Management Takes Priority

The first step is securing the airway through endotracheal intubation. Progressive drowsiness after head trauma with vomiting signals deteriorating neurological status and imminent loss of airway protective reflexes. 1 Children with GCS ≤8 or clinical signs of raised intracranial pressure require elective intubation and mechanical ventilation to protect the airway. 2, 1 Even though this child's GCS is currently above 8, the progressive deterioration (drowsiness, nausea, vomiting) indicates ongoing intracranial pathology that will likely worsen. 1

Do not delay airway management to obtain additional imaging or await neurosurgical consultation. The airway must be secured before any diagnostic or therapeutic procedure. 1 A secured airway allows control of ventilation to maintain normocapnia (PaCO₂ 35-40 mmHg), which prevents secondary brain injury from hypoxia or hypercapnia-induced increases in intracranial pressure. 2, 1, 3

Critical Technical Points for Intubation

• Perform rapid-sequence intubation with cervical spine precautions (jaw thrust without head tilt) to minimize neck movement. 1
• Initiate end-tidal CO₂ monitoring immediately during intubation to maintain appropriate ventilation. 3
• Avoid rapid increases in PaCO₂ during initiation of mechanical ventilation, as this can exacerbate intracranial hypertension. 2, 1
• Maintain adequate blood pressure (systolic >110 mmHg in school-age children) to ensure cerebral perfusion, as hypotension dramatically worsens neurological outcome. 2, 3

Urgent Neurosurgical Evaluation for Hematoma Evacuation

Once the airway is secured, immediate neurosurgical consultation is mandatory. 1, 3 The crescent-shaped bleeding on CT represents an acute subdural hematoma, which requires surgical evacuation in the setting of neurological deterioration. 4

Indications for Surgical Evacuation

This patient meets criteria for urgent surgical intervention based on:

• Progressive neurological deterioration (drowsiness, decreased GCS) despite initial GCS >8. 4
• Acute subdural hematoma with clinical evidence of mass effect (altered consciousness, vomiting). 5, 4
• Patients with GCS 14 and neurological symptoms have approximately 23% risk of requiring neurosurgical intervention. 6

Surgical evacuation should be performed as soon as possible after airway stabilization. 4 Craniotomy with or without bone flap removal is the preferred surgical approach for acute subdural hematoma evacuation, as it provides better outcomes than burr holes. 5, 4, 7

Absolute Surgical Indications (Even Without Deterioration)

For reference, acute subdural hematoma with thickness >10mm or midline shift >5mm requires surgical evacuation regardless of GCS score. 4 However, this child's clinical deterioration makes surgery necessary even if these radiographic thresholds are not met. 4

Why Other Options Are Incorrect

Reassurance (Option C) is dangerous and inappropriate. Progressive drowsiness with vomiting after head trauma represents ongoing intracranial bleeding until proven otherwise, and early intervention is mandatory. 1 Clinical deterioration can occur rapidly, and the window for optimal surgical intervention may be missed. 6

MRI (Option D) is not indicated in the acute setting. CT scan has already confirmed the diagnosis of acute subdural hematoma. 2 MRI requires longer acquisition time and is not appropriate when the patient has a deteriorating neurological examination requiring urgent intervention. 2

Hematoma evacuation alone (Option B) without first securing the airway is incorrect sequencing. Airway control is the absolute priority before neurosurgical intervention. 1, 3 Operating on a patient with an unprotected airway and deteriorating consciousness creates unacceptable risk of aspiration, hypoxia, and secondary brain injury. 2, 1

Critical Pitfalls to Avoid

• Never postpone airway management to obtain additional imaging or await surgical preparation. The airway must be secured first. 1
• Do not assume that GCS >8 means the patient is stable. Progressive drowsiness with vomiting indicates ongoing deterioration requiring immediate action. 1, 6
• Avoid hyperventilation except for imminent herniation. Target normocapnia (PaCO₂ 35-40 mmHg) to prevent cerebral vasoconstriction and ischemia. 2, 1, 3
• Do not delay neurosurgical consultation once the airway is secured. Time to surgical evacuation affects outcome in acute subdural hematoma. 4

Post-Intubation Management Priorities

After securing the airway:

• Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion. 3
• Consider ICP monitoring if GCS remains ≤8 after intubation, targeting ICP <20 mmHg. 3, 4
• Proceed immediately to operating room for craniotomy and hematoma evacuation. 4
• Transfer to pediatric trauma center with PICU capabilities if not already at one. 3

Answer: A - Intubate and secure the airway (followed immediately by neurosurgical hematoma evacuation once airway is protected).