Most Appropriate Management: Intubation and Spine Protection
In a young child with post-traumatic seizure, vomiting, scalp swelling, and progressive drowsiness following a fall from height, the most appropriate immediate management is endotracheal intubation with cervical spine immobilization (Option B). This child has a Glasgow Coma Scale ≤8 (indicated by progressive sleepiness after seizure) and requires definitive airway protection before any surgical intervention.
Clinical Reasoning
Why Intubation Takes Priority Over Hematoma Evacuation
GCS ≤8 mandates immediate endotracheal intubation without delay in trauma patients, as this is a non-negotiable, time-critical intervention to prevent airway loss, aspiration (especially after vomiting), and hypoxemia 1.
Progressive drowsiness after head trauma with seizure and vomiting indicates severe traumatic brain injury requiring immediate airway control before any diagnostic imaging or surgical planning 1.
Hematoma evacuation cannot be safely performed without a secured airway in an obtunded child with impaired consciousness and active vomiting 2.
Cervical Spine Protection is Mandatory
All pediatric trauma patients with significant mechanism (fall from height) require cervical spine immobilization until injury is excluded, as cervical spine injury occurs in up to 3-6% of trauma patients 3, 4.
Apply a rigid cervical collar with manual in-line stabilization (MILS) immediately to prevent onset or worsening of neurological deficit 5, 6.
The anterior portion of the cervical collar should be removed during intubation attempts while maintaining MILS to improve mouth opening and glottic visualization without compromising spinal protection 5, 6, 1.
Recommended Intubation Technique
Rapid Sequence Induction Protocol
Use rapid sequence induction (RSI) with direct laryngoscopy as this provides the highest first-attempt success rate in pediatric trauma 1.
Pre-oxygenate with 100% FiO₂ before any intubation attempt to minimize hypoxemia, which is particularly critical in traumatic brain injury 2, 1.
Incorporate a gum-elastic bougie to increase first-pass success while maintaining cervical spine alignment 1.
Critical Technical Points
Do NOT use the Sellick maneuver (cricoid pressure) as it increases cervical spine movement and should be avoided 5, 6, 1.
Use cuffed endotracheal tubes in children rather than uncuffed tubes, with cuff pressure monitored and maintained <20 cmH₂O 2.
Limit intubation attempts to three maximum to reduce airway trauma, bleeding, and edema that compromise subsequent management 1.
Hemodynamic Management During Intubation
Maintain systolic blood pressure >110 mmHg continuously before and during airway management, as hypotension increases mortality in traumatic brain injury 5, 6.
Target mean arterial pressure ≥70 mmHg to prevent secondary brain injury from hypoperfusion 5, 6.
Prepare for concurrent fluid resuscitation as positive-pressure ventilation can precipitate severe hypotension in hypovolemic trauma patients 1.
Post-Intubation Management Sequence
After Airway is Secured
Insert a nasogastric tube to decompress the stomach (important after vomiting and in mechanically ventilated patients) 2.
Obtain CT head and cervical spine without IV contrast as the initial imaging studies to identify intracranial hematoma and cervical spine injury 5, 6.
Neurosurgical consultation for hematoma evacuation can only proceed safely once the airway is definitively secured and imaging is complete 5.
Common Pitfalls to Avoid
Never attempt hematoma evacuation before securing the airway in an obtunded, vomiting child—this risks catastrophic airway loss and aspiration during surgery 2, 1.
Never leave the cervical collar fully in place during intubation, as this significantly worsens glottic visualization and increases failure rates 5, 6.
Do not delay intubation for imaging when GCS ≤8—airway protection takes absolute priority over diagnostic studies 1.
Avoid nasotracheal intubation in pediatric trauma due to increased risk of basilar skull fracture (especially with scalp swelling suggesting skull fracture), technical difficulty, and longer procedural time 1.