Management of Pediatric Extradural Hematoma with Neurological Deterioration
Intubate and secure the airway immediately, then proceed directly to emergent surgical evacuation of the hematoma. 1, 2, 3
Immediate Airway Management (First Priority)
Rapid-sequence intubation must be performed immediately because this child has decreased consciousness (sleepiness), recurrent vomiting, and focal neurological deficit (left-sided weakness)—all of which indicate inability to protect the airway and create high aspiration risk. 1, 2
- The combination of vomiting and altered mental status represents an imminent aspiration hazard that must be addressed before any other intervention, including surgery. 2, 3
- A Glasgow Coma Scale ≤8 or any child with decreased consciousness warrants elective intubation and ventilation. 4
- Maintain systolic blood pressure >110 mmHg during intubation using vasopressors (phenylephrine or norepinephrine) without delay, as even a single episode of hypotension markedly worsens neurological outcomes. 1, 3
- Use cervical spine precautions during intubation given the mechanism of a 2-meter fall. 1
- Confirm tube placement with end-tidal CO₂ monitoring and maintain normocapnia (normal PaCO₂), avoiding hyperventilation unless signs of herniation develop. 3
Emergent Surgical Evacuation (Immediate Second Priority)
Once the airway is secured, proceed immediately to craniotomy for hematoma evacuation—the presence of focal neurological deficit (left-sided weakness) is an absolute indication for immediate neurosurgical intervention. 1, 2
- Focal weakness reflects significant brain compression and mass effect that can only be reversed by surgical decompression. 1, 2
- Surgery should be performed within 4 hours of injury whenever feasible, as earlier hematoma removal is associated with better neurological outcomes and reduced mortality. 1, 2
- The American College of Surgeons and Neurocritical Care Society state that any extradural hematoma causing focal neurological signs mandates immediate surgical treatment. 1
- Delaying surgery for "medical stabilization" in symptomatic patients leads to neurological deterioration and poorer outcomes—surgery must not be postponed. 1, 3
Why Both Interventions Are Mandatory
Simultaneous airway protection and preparation for urgent surgical evacuation are required because decreased consciousness signals impending herniation, and focal deficits confirm mass effect that only surgery can reverse. 1
- Delaying intubation to rush to surgery risks aspiration, hypoxemia, or hypercarbia, which worsen neurological outcomes. 3
- Conversely, delaying surgery after airway control allows progressive brain compression and herniation. 1, 2
Post-Operative Management
After hematoma evacuation, the child requires ICU monitoring with intracranial pressure (ICP) monitoring. 1, 2, 3
- Maintain cerebral perfusion pressure between 60-70 mmHg to optimize cerebral blood flow. 2, 3
- Continue mechanical ventilation with end-tidal CO₂ monitoring to maintain normocapnia. 3
- Serial neurological examinations should be performed every 4 hours minimum, as 30-40% of hematomas expand in the first 12-36 hours. 2
- Maintain platelet count >100,000/mm³ and correct any coagulopathy. 3
- Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes. 3
Critical Pitfalls to Avoid
- Do not delay intubation to "get to the OR faster"—aspiration during transport or induction will worsen outcomes. 3
- Do not delay surgery for prolonged medical optimization—focal deficits mandate immediate decompression. 1
- Do not apply conservative management criteria (GCS 13-15, hematoma <30-40mm, midline shift <5-6mm) to this patient, as these apply only to asymptomatic or minimally symptomatic patients without focal deficits. 5, 6
- This child has focal weakness and decreased consciousness, which are absolute contraindications to conservative management. 1, 2