eMedicine Specialties > Neurology > Critical Care Neurology
Epidural Hematoma: Treatment & Medication
Updated: Mar 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
Initial resuscitation efforts should include assessment and stabilization of airway patency, breathing, and circulation. A thorough trauma evaluation is mandatory, including inspection for skull fractures and appreciation of the force and location of impact. Immobilization of the spine should be followed by emergent transfer of the patient to the nearest level I trauma center supported with neurosurgical consultation.
- Triage and initial management of a patient with epidural hematoma may be tailored to the degree of neurological impairment at presentation. Alert patients may be evaluated with a CT scan following a brief neurologic examination.
- A patient with a small epidural hematoma may be treated conservatively, though close observation is advised, as delayed, yet sudden, neurological deterioration may occur.
- Trauma patients may require diagnostic peritoneal lavage and radiographs of the chest, pelvis, and cervical spine.
- While neurosurgical consultation is requested, administer intravenous fluids to maintain euvolemia and to provide adequate cerebral perfusion pressure.
- Patients with elevated intracranial pressure may be treated with osmotic diuretics and hyperventilation, with elevation of the head of the bed at an angle of 30 degrees. Patients who are intubated may be hyperventilated with intermittent mandatory ventilation at a rate of 16-20 breaths per minute and tidal volume of 10-12 mL/kg. A carbon dioxide partial pressure of 28-32 mm Hg is ideal, as severe hypocapnia (<25 mm Hg) may induce cerebral vasoconstriction and ischemia.
- Coagulopathy or persistent bleeding may require administration of vitamin K, protamine sulfate, fresh frozen plasma, platelet transfusions, or clotting factor concentrates.
Surgical Care
Although several recent reports have described successful conservative management of epidural hematoma, surgical evacuation constitutes definitive treatment of this condition. Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the bone and, occasionally, epidural drains are employed for as long as 24 hours.
- Minimally invasive surgical procedures, including the use of burr holes and negative pressure drainage, may be used in selected cases.
- Novel therapeutic approaches
- Endovascular embolization to minimize bleeding during the acute stage
- Thrombolytic evacuation using closed suction drain
CT scanning performed before and after surgical evacuation of an intracranial epidural hematoma.
Consultations
- Neurosurgeon (for potential emergent evacuation of the hematoma)
- Neurologist
- Rehabilitation specialist
Diet
The hypermetabolic and catabolic phenomena associated with severe head injury necessitate caloric supplementation. Initiate enteral feedings as soon as possible.
Activity
Patients who are treated conservatively should undergo close observation and should avoid strenuous activity. Inpatients should remain on bedrest during the initial phase; this can be followed by a progressive increase in activity.
Medication
Osmotic diuretics, such as mannitol or hypertonic saline, may be used to diminish intracranial pressure. As hyperthermia may exacerbate neurological injury, acetaminophen may be given to reduce fevers. Anticonvulsants are used routinely to avoid seizures that may be induced by cortical damage. Patients with spinal epidural hematoma may require high-dose methylprednisolone when spinal cord compression is involved. Immobilized patients may require heparin for prevention of venous thrombosis, whereas vitamin K and protamine may be administered to restore normal coagulation parameters. Antacids are used to prevent gastric ulcers associated with traumatic brain injury and spinal cord damage.
Osmotic diuretics
These agents reverse the pressure gradient across the blood-brain barrier, reducing intracranial pressure.
Mannitol (Osmitrol, Resectisol)
Reduces cerebral edema by osmotic forces and decreases blood viscosity, resulting in reflex vasoconstriction and lowering of intracranial pressure.
Adult
0.75-1 g/kg IV, followed by 0.25-0.5 g/kg IV q3-5h to maintain serum hyperosmolarity (approximately 320 mOsm/L)
Pediatric
Not established; dose is dependent on weight, clinical condition, and laboratory results
May decrease serum lithium levels
Documented hypersensitivity; anuria; severe pulmonary congestion or frank pulmonary edema; active intracranial bleeding; severe dehydration; progressive renal or cardiac failure
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Perform periodic clinical evaluation and laboratory assessment to monitor changes in serum osmolarity, fluids, and electrolytes; persistently elevated serum osmolarity may result in rebound intracranial hypertension
Caution in renal dysfunction, hypervolemia, urinary tract obstruction, or cardiovascular instability
Antipyretic agents
These agents are helpful in relieving the fever associated with the condition.
Acetaminophen (Tylenol, Feverall, Aspirin Free Anacin)
Reduces fever and maintains normothermia. DOC for pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants.
Adult
650 mg PO/PR q4-6h; not to exceed maximum daily dosage of 4 g
Pediatric
<12 years: 10-15 mg/kg/dose PO/PR q4-6h prn; not to exceed 2.6 g/d
>12 years: 325-650 mg PO/PR q4h; not to exceed 5 doses (2.6 g) in 24 h
Rifampin can reduce analgesic effects; barbiturates, carbamazepine, hydantoins, and isoniazid may increase hepatotoxicity
Documented hypersensitivity; known G-6-P deficiency; hepatic dysfunction
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Hepatotoxicity possible in patients with chronic alcoholism following various dose levels; severe or recurrent pain or high or continued fever may indicate serious illness; acetaminophen contained in many OTC products and combined use with these products may result in cumulative doses exceeding recommended maximum dose
Anticonvulsants
These agents reduce frequency of early posttraumatic seizures from 14% to 4%, but they do not prevent later seizures. If seizures are not experienced for 7-10 d, the drug may be discontinued.
Fosphenytoin (Cerebyx)
Converted to phenytoin, which modulates neuronal voltage-dependent sodium channels.
Adult
15-20 mg/kg IV loading dose, followed by 300 mg IV q24h
Pediatric
Not established; weight-adjusted dosage similar to that in adults
Amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, and valproic acid may increase toxicity;
Barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, and sucralfate decrease effects
Decreases effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, and valproic acid
Documented hypersensitivity; sinus bradycardia; sinoatrial and third-degree AV block; Adams-Stokes syndrome
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Avoid rapid administration to reduce risks of hypotension and cardiac arrhythmias; monitor for blood dyscrasias with serial blood tests; discontinue use if skin rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; use caution in patients with acute intermittent porphyria, diabetes, or hepatic dysfunction
Corticosteroids
Anti-inflammatory properties mitigate tissue damage in spinal cord compression.
Methylprednisolone (Adlone, Medrol, Solu-Medrol)
Reduces injury associated with spinal cord compression. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Adult
30 mg/kg IV bolus, followed by 4 mg/kg IV infusion over next 23 h
Pediatric
Administer as in adults
Inhibits metabolism of cyclosporine; inducers of hepatic enzymes (eg, phenobarbital, phenytoin, rifampin) increase clearance; troleandomycin and ketoconazole inhibit metabolism; variable interaction with aspirin and oral anticoagulants
Documented hypersensitivity; systemic fungal infection
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Caution in ulcerative colitis, peptic ulcer disease, renal insufficiency, hypertension, osteoporosis, myasthenia gravis, hypothyroidism, cirrhosis, and ocular herpes simplex; reductions in dosage should be gradual; psychic derangements may occur
Antidotes
These agents reverse some coagulopathies or bleeding diatheses.
Phytonadione; vitamin K (AquaMEPHYTON, Konakion, Mephyton)
Promotes hepatic synthesis of clotting factors that inhibit warfarin effects.
Adult
2.5-10 mg IM/SC; repeat administration q6-8h until PT normalized
Pediatric
Not established; suggested dose is as in adults
Antagonizes effects of warfarin sodium and dicumarol
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Ineffective in hereditary hypoprothrombinemia
Protamine sulfate
Neutralizes effects of heparin.
Adult
Dosage adjusted to time interval since discontinuation of IV heparin
Immediately: 1-1.5 mg/100 U heparin
30-60 min from discontinuation of heparin: 0.5-0.75 mg/100 U heparin
>60 min from discontinuation of heparin: 0.25-0.375 mg/100 U heparin
If SC heparin used, give 1-1.5 mg/100 U heparin; not to exceed 50 mg IV over 10 min
Pediatric
Not established; suggested dose is as in adults
None reported
Documented hypersensitivity
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
Anticoagulant effects may occur if maximum dose exceeded
Antacids
These agents provide prophylaxis of gastric ulcers.
Famotidine (Pepcid)
Competitively inhibits histamine at H2 receptor of gastric parietal cells, resulting in reduced gastric acid secretion, gastric volume, and hydrogen concentrations. Minimizes development of gastric ulcers.
Adult
20 mg IV/PO bid
Pediatric
Not established; suggested dose is as in adults
None reported
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dosage in patients with renal insufficiency
Anticoagulants
These agents reduce risk of venous complications in immobilized patients.
Heparin
Augments activity of antithrombin III and prevents conversion of fibrinogen to fibrin. Does not actively lyse but is able to inhibit further thrombogenesis. Prevents re-accumulation of clot after spontaneous fibrinolysis. Used for prophylaxis of deep venous thrombosis.
Adult
5000 U SC bid
Pediatric
Weight-adjusted dosage
Antiplatelet agents may exacerbate hemorrhagic risk associated with heparin; digitalis, tetracyclines, nicotine, and antihistamines may interfere with heparin; precipitates may form when used in conjunction with doxorubicin, droperidol, ciprofloxacin, or mitoxantrone
Documented hypersensitivity; subacute bacterial endocarditis; active bleeding; history of heparin-induced thrombocytopenia
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
Precautions
In neonates, preservative-free heparin recommended to avoid possible toxicity (ie, gasping syndrome) by benzyl alcohol, which is used as preservative; caution in severe hypotension and shock; monitor for bleeding in peptic ulcer disease, menstruation, increased capillary permeability, and when giving IM injections; discontinue use if thrombocytopenia develops
More on Epidural Hematoma |
| Overview: Epidural Hematoma |
| Differential Diagnoses & Workup: Epidural Hematoma |
 Treatment & Medication: Epidural Hematoma |
| Follow-up: Epidural Hematoma |
| Multimedia: Epidural Hematoma |
| References |
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Further Reading
Keywords
epidural hemorrhage, extradural hematoma, extradural hemorrhage, cerebral epidural hematoma, spinal epidural hematoma, EDH, SEDH, head injury, intracranial epidural hematoma
