Progressive Drowsiness After an Apparently Minor Fall in a Child: Early Recognition of Temporal Epidural Hematoma and the Importance of Timely Neurosurgical Referral

Abstract

Background: Traumatic brain injury (TBI) is a major cause of preventable morbidity and mortality in children. Although most pediatric head injuries are classified as minor, clinically important intracranial hemorrhage may occur after apparently low-energy trauma. Early recognition of neurological deterioration and timely neuroimaging are therefore essential. Case Presentation: We report the case of a 5-year-old girl who sustained an approximately 1-meter fall from her bed during the night. Approximately 1–2 hours after the injury, she developed repeated vomiting and progressive drowsiness. A temporal scalp hematoma was present, while no obvious skull deformity or major external cranial injury was identified. Her initial Glasgow Coma Scale (GCS) score was 12/15. Because of the combination of pediatric head trauma, vomiting, progressive alteration in consciousness, and impaired GCS, clinically significant intracranial injury was suspected. Diagnostic Assessment and Management: Urgent non-contrast cranial computed tomography (CT) demonstrated a right temporal epidural hematoma without an associated skull fracture. Intravenous access was established, supplemental oxygen was administered because of an initial oxygen saturation of approximately 90%, and laboratory investigations were obtained. CT imaging was completed approximately 20 minutes after emergency department presentation. Neurosurgical consultation was initiated immediately after the radiological diagnosis. The patient was transferred urgently to neurosurgical care and subsequently underwent emergency surgical evacuation of the epidural hematoma. Conclusion: This case illustrates that a seemingly minor mechanism of injury does not exclude clinically significant intracranial hemorrhage in children. Progressive drowsiness and impaired consciousness should be regarded as important warning signs requiring prompt reassessment and neuroimaging. Rapid CT acquisition, early neurosurgical communication, and avoidance of unnecessary delays may be critical in preventing secondary neurological deterioration.