A young child who fell from a tree presents with seizure, vomiting, scalp swelling and progressive drowsiness. What is the most appropriate immediate management?

Immediate Management: Intubation and Spine Protection

B. Intubation and spine protection is the most appropriate immediate management for this child with severe traumatic brain injury. This child presents with post-traumatic seizure, vomiting, altered consciousness (sleepiness), and visible head swelling—all indicators of severe traumatic brain injury requiring immediate airway control before any other intervention 1.

Why Airway Control Takes Priority

Intubation with spine protection must be performed immediately in children with severe traumatic brain injury, as it decreases mortality and is the absolute priority before neurosurgical intervention 1. This child's presentation—seizure followed by vomiting and progressive drowsiness—indicates:

• Depressed conscious level automatically classifies this as high-risk severe head trauma requiring urgent supportive management 2
• Active seizure activity or irregular respirations with pooling saliva/vomit in the mouth are indications for immediate intubation 2
• Progressive sleepiness suggests deteriorating neurological status and impending respiratory compromise 2

The combination of post-traumatic seizure with altered mental status carries a 16-44% risk of intervention-requiring intracranial injury 1. Pre-hospital or emergency department intubation improves survival with early airway control compared to delayed intubation 1.

Why Hematoma Evacuation is NOT the First Step

While this child likely has an intracranial hematoma given the clinical presentation, airway control must precede neurosurgical intervention 1. Hematoma evacuation cannot be safely performed without:

• Controlled ventilation to maintain normocapnia (PaCO₂ 35-40 mmHg) and prevent secondary brain injury 1
• Prevention of hypoxia or hypercapnia, which worsen neurological outcomes 1
• Ability to manage intracranial pressure during surgical intervention 1

Critical Management Sequence

Step 1: Immediate Airway Control

• Intubate with inline cervical spine stabilization—never assume the spine is uninjured after a fall from height 1
• Initiate end-tidal CO₂ monitoring during intubation to maintain appropriate ventilation, as hypocapnia causes cerebral vasoconstriction and brain ischemia 1
• Avoid hyperventilation unless there are signs of acute herniation 1

Step 2: Hemodynamic Stabilization

• Maintain systolic blood pressure >110 mmHg to ensure adequate cerebral perfusion, as hypotension dramatically worsens neurological outcome 1
• Never allow hypotension in pediatric TBI patients, even when hemorrhagic shock is present elsewhere 1

Step 3: Urgent Neuroimaging

• Obtain urgent CT scan of head and cervical spine without delay to identify surgical lesions 1, 3
• Post-traumatic seizures indicate possible intracranial hemorrhage requiring immediate intervention 3

Step 4: Neurosurgical Consultation

• Immediate neurosurgical consultation for epidural hematoma with mass effect, expanding intracranial lesion, or depressed skull fracture 1

Common Pitfalls to Avoid

• Never delay intubation to obtain imaging first—airway control precedes all diagnostic studies in severe TBI 1
• Never assume the child is "just postictal" when progressive drowsiness develops—this indicates evolving intracranial pathology 2
• Never give anything by mouth to a child with decreased responsiveness after seizure, as aspiration risk is high 1
• Never hyperventilate aggressively without ICP monitoring—this can cause cerebral ischemia 2, 1

Additional Critical Considerations

• Children with post-traumatic seizures and altered mental status require transfer to a pediatric trauma center with dedicated PICU capabilities 1
• Maintain high index of suspicion for inflicted trauma (non-accidental trauma) in children <2 years old 1
• ICP monitoring should be considered if GCS ≤8 with abnormal CT findings, targeting ICP <20 mmHg 1

The evidence is unequivocal: airway control with spine protection is the immediate priority, followed by imaging and neurosurgical intervention 1. Attempting hematoma evacuation without securing the airway first would be dangerous and potentially fatal 1.