A 28-year-old male construction worker is brought to the emergency department 45 minutes after a fall from scaffolding onto concrete. On arrival, he is alert but confused, with a GCS of 13 (E3V4M6). His pupils are equal and reactive. CT head shows a small subdural hematoma without midline shift. Blood pressure is 128/82 mmHg, heart rate 92/min, respiratory rate 18/min. After initial stabilization, what is the most appropriate next step in management?

Explanation

## Management of Acute Subdural Hematoma with GCS 13 **Key Point:** A patient with GCS 13 and a small subdural hematoma without midline shift or mass effect is classified as a **moderate head injury**. The absence of neurological deterioration, pupillary changes, or significant mass effect does NOT mandate immediate surgery. **High-Yield:** Management of acute subdural hematoma depends on: 1. **Volume and mass effect** (midline shift, compression of ventricles) 2. **GCS score** (reflects severity) 3. **Pupillary status** (indicates herniation risk) 4. **Neurological trajectory** (improving vs. deteriorating) ### Decision Algorithm for Acute SDH ```mermaid flowchart TD A[Acute SDH on CT]:::outcome --> B{Midline shift OR<br/>GCS ≤ 8?}:::decision B -->|Yes| C[Neurosurgery consult<br/>Operative evacuation]:::action B -->|No| D{Hematoma volume<br/>or mass effect?}:::decision D -->|Significant| E[Consider surgery<br/>based on trajectory]:::action D -->|Minimal| F[ICU admission<br/>Serial neuro checks<br/>Repeat CT if decline]:::action F --> G{GCS drops ≥2<br/>or pupil change?}:::decision G -->|Yes| H[Urgent neurosurgery<br/>Operative evacuation]:::urgent G -->|No| I[Continue monitoring<br/>Discharge when stable]:::outcome ``` **Clinical Pearl:** Small acute SDH (thickness < 10 mm, no midline shift) in a patient with GCS ≥ 13 and stable pupils can be managed **non-operatively** with: - ICU-level care for continuous monitoring - Serial neurological examinations (q1h initially) - Repeat CT if there is ANY deterioration - Neurosurgery on standby (not routine OR) **Warning:** Do NOT discharge home immediately — even small SDH can expand or cause delayed deterioration. The patient requires ICU monitoring for at least 24–48 hours. **Mnemonic: SDHS** (Subdural Hematoma Surgery criteria) - **S**hift (midline shift present) → Surgery - **D**eterioration (GCS drop ≥2) → Surgery - **H**erniation signs (blown pupil) → Surgery - **S**mall SDH + stable → Supportive care + monitor [cite:ATLS 10th Edition, Chapter 4: Initial Assessment and Management]