A 28-year-old man is brought to the emergency department 20 minutes after a motor vehicle collision. On examination, he is drowsy, opens eyes to pain, and localizes to pain. His pupils are equal and reactive. CT head shows a 12 mm acute subdural hematoma with 4 mm midline shift. His GCS is 12 (E3V4M5). Vital signs are stable. What is the most appropriate next step in management?

Explanation

## Clinical Context This patient has a moderate head injury (GCS 12) with an acute subdural hematoma (ASDH) and significant mass effect (4 mm midline shift). The combination of altered consciousness, imaging findings, and hemodynamic stability requires urgent neurosurgical intervention. ## Key Point: **Acute subdural hematoma with GCS ≤12 and/or midline shift >5 mm is a neurosurgical emergency requiring operative evacuation.** The patient's GCS of 12 and 4 mm shift meet criteria for urgent surgery. ## Management Algorithm ```mermaid flowchart TD A[Acute SDH on CT]:::outcome --> B{GCS ≤12 OR midline shift >5mm?}:::decision B -->|Yes| C[Intubate & stabilize]:::action C --> D[Osmotic therapy: Mannitol/Hypertonic saline]:::action D --> E[Urgent neurosurgery consultation]:::action E --> F[Operating room for evacuation]:::action B -->|No| G[ICU observation + serial neuro checks]:::action G --> H[Repeat CT if deterioration]:::action F --> I[Postoperative ICU care]:::outcome ``` ## Rationale for Correct Answer **Intubation, osmotic therapy, and urgent neurosurgical consultation** is the correct sequence because: 1. **Airway protection**: GCS 12 is at the threshold for intubation (GCS ≤8 is absolute; GCS 9–12 with deteriorating trend or airway compromise requires intubation). 2. **Reduce ICP**: Osmotic agents (mannitol 0.25–1 g/kg IV bolus or 3% hypertonic saline) lower ICP acutely while awaiting surgery. 3. **Urgent neurosurgery**: The 4 mm midline shift + GCS 12 meets operative criteria; delay increases risk of herniation. 4. **Avoid delay**: Burr holes without formal imaging localization are obsolete in the CT era; immediate surgery in the OR is the standard. ## High-Yield: **GCS ≤12 + mass effect = neurosurgical emergency.** Do not observe; do not repeat imaging first. Stabilize airway, reduce ICP, and get the neurosurgeon involved immediately. ## Clinical Pearl: The 4 mm midline shift is already significant (>3 mm suggests mass effect); combined with GCS 12, this is NOT a "wait and see" case. Mortality increases sharply if surgery is delayed beyond 4 hours from injury in symptomatic ASDH.