A 28-year-old male construction worker is brought to the emergency department 30 minutes after a fall from a 15-foot scaffold. He was initially conscious but became increasingly drowsy over the past 10 minutes. On examination, his Glasgow Coma Scale (GCS) score is 12 (E3V4M5). Pupils are equal and reactive. Blood pressure is 145/92 mmHg, heart rate 88/min, respiratory rate 18/min. Non-contrast CT head shows a lens-shaped hyperdensity in the right frontoparietal region with midline shift of 4 mm. What is the most appropriate immediate management?

Explanation

## Clinical Diagnosis The lens-shaped hyperdensity in the frontoparietal region with midline shift indicates an **acute epidural haematoma** — a neurosurgical emergency. **Key Point:** Epidural haematoma is a **space-occupying lesion** that causes mass effect and increased intracranial pressure (ICP). The presence of midline shift (4 mm) and GCS decline from initial consciousness indicates **herniation risk**. ## Management Algorithm ```mermaid flowchart TD A[Acute epidural haematoma with midline shift]:::outcome --> B{GCS < 8?}:::decision B -->|No, but mass effect present| C[ICP reduction agents]:::action C --> D[Mannitol 1 g/kg IV bolus]:::action D --> E[Urgent neurosurgical consultation]:::action E --> F[Evacuation in OR]:::action B -->|Yes| G[Intubate + hyperventilate]:::action G --> F ``` ## Immediate Steps 1. **Osmotic therapy (Mannitol):** Reduces ICP acutely by creating an osmotic gradient; onset within 15–30 minutes. 2. **Neurosurgical consultation:** This patient requires **operative evacuation** — epidural haematomas do not resolve conservatively when mass effect and midline shift are present. 3. **Avoid delays:** Transfer to a neurosurgery-capable centre simultaneously. **High-Yield:** GCS 12 + midline shift + lens-shaped bleed = **surgical emergency**. Do not observe; do not give steroids alone. **Clinical Pearl:** The "lucid interval" (initial loss of consciousness, recovery, then deterioration) is classic for epidural haematoma but not always present. Midline shift is the key indicator of need for surgery regardless of GCS. **Mnemonic:** **SHED** — Subdural (crescent), Haematoma (epidural = lens), Evacuation (urgent), Deterioration (GCS drop). [cite:ATLS 10th Edition Ch 4, Neurosurgery Principles]