In a 6‑7‑year‑old child who fell, is now drowsy, nauseated, vomiting, with a Glasgow Coma Scale above 8 but below baseline and a CT scan showing an acute crescent‑shaped subdural hematoma, what is the best immediate management?

Immediate Airway Management (Intubation) is the Best Management

In a 6-7 year-old child with acute subdural hematoma presenting with progressive drowsiness, vomiting, and decreased GCS (but >8), the priority is to secure the airway through endotracheal intubation before proceeding to hematoma evacuation. 1

Why Airway Control Takes Precedence

• Progressive drowsiness after head trauma signals deteriorating neurological status and imminent loss of airway protective reflexes, making airway protection the absolute first priority before any diagnostic or therapeutic procedure 1
• The combination of vomiting and altered consciousness creates immediate aspiration risk that cannot be safely managed without a definitive airway 1
• Airway control must be secured before neurosurgical intervention; operating on a patient with an unprotected airway significantly increases the risk of aspiration, hypoxia, and secondary brain injury 1

Clinical Decision Algorithm

Step 1: Recognize High-Risk Features

• This child meets multiple high-risk criteria per PECARN: altered mental status (drowsiness), vomiting, and decreased GCS 2
• CT confirmation of crescent-shaped (subdural) hematoma establishes this as a neurosurgical emergency 2

Step 2: Secure Airway FIRST

• Perform rapid-sequence intubation with cervical spine precautions (jaw thrust without head tilt) to minimize neck movement while establishing a definitive airway 1
• Children with deteriorating consciousness after head trauma require elective endotracheal intubation and mechanical ventilation to protect the airway 1
• The GCS threshold of ≤8 is a guideline, not an absolute rule; progressive drowsiness with vomiting mandates airway protection regardless of the exact GCS number 1, 3

Step 3: Optimize Ventilation Parameters

• Maintain normocapnia (PaCO₂ 35-40 mmHg) to prevent secondary brain injury from hypercapnia-induced ICP elevation 1, 3
• Avoid rapid increases in PaCO₂ during initiation of mechanical ventilation, as this exacerbates intracranial hypertension 1
• Reserve hyperventilation only for imminent herniation signs 1

Step 4: Ensure Adequate Cerebral Perfusion

• Maintain systolic blood pressure >110 mmHg in school-age children to ensure adequate cerebral perfusion 1
• Hypotension dramatically worsens neurological outcome and must be avoided 1, 3

Step 5: Proceed to Neurosurgical Evacuation

• Once the airway is protected and ventilation optimized, promptly involve neurosurgery for definitive hematoma evacuation 1
• Surgical evacuation should be performed as soon as possible after airway is secured 4

Why Other Options Are Incorrect

Option B (Hematoma Evacuation) - Wrong Sequence

• While hematoma evacuation is ultimately necessary, attempting surgery before securing the airway places the child at unacceptable risk of aspiration and hypoxic brain injury 1
• The evidence is clear that airway control precedes surgical intervention 1

Option C (Reassurance) - Dangerous

• Reassurance is appropriate only for very low-risk patients with normal mental status and no concerning features 5
• This child has multiple high-risk features (altered mental status, vomiting, confirmed intracranial bleeding) that absolutely contraindicate observation alone 2

Option D (MRI) - Impractical and Delays Care

• MRI requires longer acquisition time and is unsuitable for patients with deteriorating neurological status 2, 1
• CT has already confirmed the diagnosis; MRI adds no value in the acute setting and dangerously delays definitive management 2
• MRI should not be employed in the acute phase when urgent neurosurgical intervention is required 1

Critical Pitfalls to Avoid

• Do not postpone airway management to obtain additional imaging or await neurosurgical consultation; the airway must be secured first 1
• Do not assume a GCS >8 means the airway is safe; progressive drowsiness with vomiting indicates imminent decompensation 1, 3
• Do not hyperventilate aggressively without ICP monitoring, as this can induce cerebral ischemia 3
• Never dismiss progressive drowsiness as a simple post-ictal state; it reflects evolving intracranial pathology requiring urgent intervention 3

Evidence Strength

The recommendation for immediate intubation before hematoma evacuation comes from high-quality guideline evidence 1 that explicitly addresses this clinical scenario and sequence of care. While neurosurgical guidelines 4 establish criteria for surgical evacuation of subdural hematomas, they assume a protected airway. The pediatric trauma guidelines 2, 3 consistently emphasize that airway management precedes all other interventions in children with deteriorating consciousness after head trauma.