A trauma patient with blunt head injury has a GCS of 7 on arrival. CT head shows a right-sided acute epidural haematoma (EDH) with maximum thickness 18 mm, volume 35 mL, and midline shift of 6 mm. The pupil is fixed and dilated on the right. According to Bullock et al. (BTF/AANS Guidelines), what is the most appropriate management?
- A Emergency craniotomy regardless of GCS, given volume > 30 mL, thickness > 15 mm, or midline shift > 5 mm ✓
- B Non-operative management with ICP monitoring and close neuro-observation
- C Burr hole evacuation under local anaesthesia as a temporising measure
- D Decompressive craniectomy (removal of bone flap) as primary treatment
Explanation
Brain Trauma Foundation (BTF) guidelines state that EDH with volume > 30 mL, clot thickness > 15 mm, or midline shift > 5 mm should undergo emergency surgical evacuation regardless of GCS. This patient meets all three criteria (volume 35 mL, thickness 18 mm, shift 6 mm) and has a fixed dilated pupil (impending transtentorial herniation). Emergency craniotomy is required immediately. Non-operative management is only appropriate for small-volume (< 30 mL, < 15 mm thick, < 5 mm shift) EDH in GCS > 8 patients. Burr hole alone is an outdated temporising measure. Decompressive craniectomy is reserved for refractory raised ICP or severe diffuse injury, not first-line for EDH.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.