In a child with a traumatic epidural hematoma presenting with vomiting, decreased consciousness, and left‑sided weakness, should the first step be airway protection (intubation) or immediate surgical evacuation of the hematoma?

Immediate Airway Protection Followed by Urgent Surgical Evacuation

In a child with traumatic epidural hematoma presenting with decreased consciousness (sleepiness), recurrent vomiting, and focal neurological deficit (left-sided weakness), the first priority is immediate endotracheal intubation to secure the airway, followed immediately by urgent neurosurgical evacuation of the hematoma. Both interventions are life-saving and must occur in rapid sequence—airway security enables safe anesthesia for surgery, while the focal deficit mandates hematoma removal to prevent irreversible brain injury. 1

Why Airway Protection Must Come First

Aspiration Risk and Inability to Protect Airway

• Rapid-sequence intubation must be performed immediately because recurrent vomiting combined with altered mental status creates an immediate and severe aspiration risk, and the child's drowsiness indicates inability to protect the airway. 1, 2
• The combination of vomiting and decreased consciousness in a head-injured child makes aspiration the most immediate life-threatening complication that can occur within seconds, whereas surgical delay of even 30-60 minutes (while securing the airway) does not preclude excellent outcomes if the airway is protected. 1
• All trauma patients are assumed to have delayed gastric emptying due to sympathetic responses, further increasing aspiration risk during any procedure. 2

Neurological Deterioration Mandates Airway Control

• Children with Glasgow Coma Scale ≤8 or rapidly deteriorating consciousness require intubation without delay to prevent secondary brain injury from hypoxemia or hypotension. 2
• Even brief episodes of hypoxemia or systolic blood pressure <90 mmHg markedly increase mortality and neurological morbidity in traumatic brain injury. 2
• Delaying intubation to rush to the operating room is identified as a critical pitfall—losing airway control during surgical positioning or induction would be catastrophic. 2

Technical Considerations for Pediatric Intubation

• Maintain systolic blood pressure >110 mmHg during intubation using prepared vasopressors (ephedrine, metaraminol, or noradrenaline) to preserve cerebral perfusion. 1, 2
• Apply manual in-line cervical spine stabilization during intubation given the 2-meter fall mechanism. 1, 2
• Use rapid-acting neuromuscular blockade (rocuronium or succinylcholine) to facilitate secure tube placement. 2
• Have video laryngoscopy and supraglottic airway devices immediately available as backup, since pediatric trauma airways have higher difficulty rates. 2

Why Immediate Surgical Evacuation Is Mandatory

Focal Neurological Deficit Is an Absolute Indication

• The presence of unilateral weakness is an absolute indication for immediate neurosurgical intervention because it reflects significant brain compression and mass effect that can only be reversed by craniotomy and hematoma evacuation. 1
• Any epidural hematoma causing focal neurological signs mandates immediate surgical treatment according to consensus from the American College of Surgeons and Neurocritical Care Society. 1
• After control of life-threatening hemorrhage (not present in this isolated head injury), all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention. 3

Evidence for Surgical Timing

• An epidural hematoma >30 cm³ should be surgically evacuated regardless of Glasgow Coma Scale score. 4
• Patients in coma (GCS <9) with anisocoria should undergo surgical evacuation as soon as possible—the combination of decreased consciousness and focal deficit in this child places him in this urgent category. 4
• Surgical evacuation should be performed within 4 hours of injury whenever feasible, because earlier hematoma removal is associated with better neurological outcomes. 1
• Delaying surgery in symptomatic patients leads to neurological deterioration and poorer outcomes; therefore, surgery must not be postponed for "medical stabilization" beyond securing the airway. 1

Surgical Technique

• Craniotomy provides more complete evacuation of the hematoma compared to other methods. 4
• Outcomes are directly related to preoperative neurologic status and presence of associated intracranial lesions, emphasizing the need for rapid intervention before further deterioration. 5

Algorithmic Approach

1. Immediate Actions (Simultaneous)

   • Call for neurosurgical consultation immediately. 3, 1
   • Prepare for rapid-sequence intubation with vasopressors drawn up. 1, 2
   • Ensure cervical spine precautions are in place. 1, 2

2. Airway Management (First 10-15 Minutes)

   • Perform rapid-sequence intubation with manual in-line stabilization. 1, 2
   • Maintain SBP >110 mmHg and MAP >80 mmHg throughout. 1, 2
   • Confirm tube placement with waveform capnography. 2
   • Target normocapnia (PaCO₂ 4.5-5.0 kPa) and adequate oxygenation (PaO₂ ≥13 kPa). 2

3. Immediate Transfer to Operating Room

   • Transport to OR should occur within minutes of securing the airway. 1
   • Continue hemodynamic support during transport. 1, 2
   • Have osmotic therapy (mannitol or hypertonic saline) available if signs of herniation develop. 1

4. Surgical Evacuation (Within 4 Hours of Injury)

   • Perform craniotomy for complete hematoma evacuation. 1, 4
   • Address any skull fracture or bleeding source. 6, 5

5. Post-Operative Management

   • ICU monitoring with consideration for intracranial pressure monitoring. 1
   • Maintain cerebral perfusion pressure 50-70 mmHg. 1
   • Surveillance for rebleeding, seizures, and infection. 1

Critical Pitfalls to Avoid

• Never delay intubation to obtain additional imaging or rush directly to surgery—the airway must be secured first. 2
• Never tolerate hypotension (SBP <110 mmHg) during intubation or transport—this dramatically worsens outcomes. 1, 2
• Never postpone surgery for prolonged "medical optimization" once the airway is secure—focal deficits demand immediate decompression. 1, 4
• Avoid hyperventilation except as a brief rescue for impending herniation, as routine hyperventilation worsens outcomes. 2

Nuance: Why Not Surgery First?

While the provided guidelines on nontraumatic hemorrhagic stroke 3 discuss stabilization measures and note limited benefit from supratentorial intraparenchymal hematoma evacuation in spontaneous bleeds, these recommendations do not apply to traumatic epidural hematomas in children with focal deficits. 3 Traumatic epidural hematomas are fundamentally different—they are extra-axial collections with excellent outcomes when evacuated promptly, whereas the stroke literature addresses intraparenchymal bleeds. 4, 5 The child's vomiting and decreased consciousness make immediate airway protection the enabling step that allows safe surgical intervention. 1, 2