A 28-year-old male construction worker is brought to the emergency department 45 minutes after a fall from scaffolding (3 metres). On arrival, he is drowsy but arousable to verbal commands. He opens his eyes to pain, obeys commands inconsistently, and speaks in confused sentences. His pupils are equal and reactive. CT head shows a 12 mm acute subdural haematoma without midline shift. Blood pressure is 128/82 mmHg, heart rate 92/min, respiratory rate 18/min. What is his Glasgow Coma Scale (GCS) score, and what is the most appropriate immediate management?

Explanation

## GCS Calculation **Key Point:** GCS is the sum of three components: eye opening (E), verbal response (V), and motor response (M). | Component | Finding | Score | | --- | --- | --- | | Eye Opening (E) | Opens to pain | 3 | | Verbal Response (V) | Confused speech | 4 | | Motor Response (M) | Obeys commands inconsistently | 5 | | **Total GCS** | — | **12** | ## Management of Acute Subdural Haematoma (SDH) **High-Yield:** Acute SDH management depends on haematoma volume, midline shift, and GCS score. ### Classification & Management Algorithm ```mermaid flowchart TD A[Acute SDH on CT]:::outcome --> B{Thickness & Midline Shift?}:::decision B -->|> 10 mm or > 5 mm shift| C[Surgical evacuation]:::action B -->|≤ 10 mm AND ≤ 5 mm shift| D{GCS ≤ 8?}:::decision D -->|Yes| E[Intubate + ICU + Serial CT]:::action D -->|No| F[Conservative management]:::action F --> G[Serial neuro checks + Repeat CT at 24 hrs]:::action C --> H[Neurosurgical consultation]:::action ``` **Clinical Pearl:** This patient has a 12 mm SDH (borderline) with **no midline shift** and **GCS 12** (>8). He is neurologically stable and haemodynamically normal. Conservative (non-operative) management with close monitoring is appropriate. **Key Point:** Indications for **emergency surgical evacuation** of acute SDH: - Thickness >10 mm on CT, OR - Midline shift >5 mm, OR - GCS ≤ 8 with SDH on imaging, OR - Acute neurological deterioration This patient meets **none** of these criteria. ### Monitoring Protocol 1. Admit to high-dependency unit (HDU) or ICU for continuous observation 2. Neurological assessment every 1–2 hours initially 3. Repeat CT head at 24 hours or if neurological deterioration 4. Maintain normothermia, normoxia, normal ICP 5. Avoid hypotension and hypoxia **Mnemonic: SAFE SDH** — Serial exams, Airway protection if GCS ≤8, Fluid/ICP management, Evacuation if criteria met, Subdural haematoma monitoring. ## Why Conservative Management Works Here - Small-to-moderate volume (12 mm) without mass effect - GCS 12 indicates mild-to-moderate head injury (not severe) - Stable vitals and equal reactive pupils (no herniation signs) - Majority of acute SDH <10 mm resolve spontaneously with conservative care [cite:ATLS 10e Ch 4, Neurosurgery Guidelines 2016]