eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Epidural Hematoma: Treatment & Medication

Author: Daniel D Price, MD, Director of Ultrasound Fellowship, Department of Emergency Medicine, Highland General Hospital, Alameda County Medical Center
Coauthor(s): Sharon R Wilson, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center
Contributor Information and Disclosures

Updated: Nov 18, 2009

Treatment

Prehospital Care

  • Stabilize acute life-threatening conditions and initiate supportive therapy. Airway control and blood pressure support are the most important issues.
  • Establish IV access, administer oxygen, and monitor.
  • Administer IV crystalloids to maintain adequate blood pressure.
  • Intubation, sedation, and neuromuscular blockade per protocol.
    • There is some suggestion of increased mortality with prehospital intubation in retrospective reviews of trauma patients with moderate-to-severe head injury compared with patients intubated in the ED.
    • Bag-valve-mask ventilation with good technique may be of more benefit to brain injured patients than prehospital intubation.

Emergency Department Care

  • Establish IV access, administer oxygen, monitor, and administer IV crystalloids as necessary to maintain adequate blood pressure.
  • Intubate using rapid sequence induction (RSI), which generally includes premedication with lidocaine, a cerebroprotective sedating agent (eg, etomidate), and a neuromuscular blocking agent. Lidocaine may have limited effect in this situation, yet it carries virtually no risk. Premedication with fentanyl may also help blunt a rise in ICP. Intubate after a basic neurologic examination to facilitate oxygenation, protect the airway, and allow for hyperventilation as needed.
  • Elevate head of the bed 30° after the spine is cleared, or use reverse Trendelenburg position to reduce ICP and increase venous drainage.
  • Administer mannitol 0.25-1 g/kg IV after consulting a neurosurgeon if MAP is greater than 90 mm Hg with continued clinical signs of increased ICP. This reduces both ICP (by osmotically reducing brain edema) and blood viscosity, which increases cerebral blood flow and oxygen delivery. Fluids must be replaced and hypovolemia avoided.
  • Hyperventilation to partial pressure of carbon dioxide (PCO2) of 30-35 mm Hg treats incipient herniation or signs of increasing ICP; however, this is controversial. Be careful not to lower PCO2 too far (<25 mm Hg). Perform hyperventilation if clinical signs of increased ICP progress and are refractory to sedation, paralysis, osmotic diuretics, and if possible, CSF drainage. This procedure reduces ICP by hypocarbic vasoconstriction and reduces risks of hypoperfusion and death of injured cells.
  • Phenytoin reduces the incidence of early posttraumatic seizures, although it does not affect late-onset seizures or the development of a persistent seizure disorder.
  • Several treatment guidelines on various aspects of traumatic brain injury are available from the Brain Trauma Foundation.2,3,4,5,6,7,8,9

Consultations

  • Consult a neurosurgeon immediately for EDH evacuation and repair.
  • Consult a trauma surgeon for other life-threatening injuries.

Medication

Use RSI when intubating to minimize rises in ICP and catecholamine release. Etomidate, when used as RSI sedating agent, maintains blood pressure, lowers ICP and brain metabolism, and has rapid onset and brief duration. Thiopental is not recommended because of its predictable effect in lowering blood pressure, the leading cause of secondary brain injury. Mannitol osmotically reduces ICP and improves blood flow. Phenytoin provides prophylaxis against early posttraumatic seizure. Once the patient has received adequate fluids, pressors such as norepinephrine can be used to maintain MAP >90 mm Hg.

Osmotic diuretic

Osmotically reduces brain edema and ICP and reduces blood viscosity, improving cerebral blood flow and oxygen delivery. Prior to ICP monitoring, use only for signs of herniation or progressive neurological deterioration. Hypovolemia should be avoided by replacing fluids (urine monitoring with placement of a bladder catheter is essential). Intermittent boluses may be more effective than continuous infusion.


Mannitol (Osmitrol)

Keeps serum osmolality <320 mOsm to prevent renal failure. Maintain euvolemia with adequate IV fluid replacement. Foley catheter is essential.

Adult

0.25-1 g/kg IV q30-60min

Pediatric

Administer by weight as in adults

Documented hypersensitivity; anuria; severe pulmonary congestion; severe dehydration; active intracranial bleeding; progressive renal damage; progressive heart failure; SBP <90 mm Hg

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

Large crystals may form in a cold solution; carefully evaluate cardiovascular status before rapid administration, as sudden increase in extracellular fluid may lead to fulminating CHF; if blood is coadministered, add at least 20 mEq of sodium chloride to each L of mannitol solution to avoid pseudoagglutination; do not administer electrolyte-free mannitol solutions with blood

Antiepileptic

Prevents early posttraumatic seizure, which can increase ICP and neurotransmitter release as well as alter blood pressure and oxygen delivery.


Phenytoin (Dilantin)

DOC for seizure prophylaxis. Fosphenytoin allows more rapid infusion and fewer side effects. If actively seizing, coadminister benzodiazepine.

Adult

17 mg/kg IV; mix in NS (precipitates in D5W); infuse no faster than 50 mg/min

Pediatric

Administer by weight as in adults

Increased toxicity with amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, valproic acid; effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, sucralfate; may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, valproic acid

Documented hypersensitivity; because of effects on ventricular automaticity, do not use in sinoatrial block, sinus bradycardia, second- and third-degree AV block, or in patients with Adams-Stokes syndrome

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Administer slowly (50 mg/min) to avoid hypotension; avoid extravasation; perform blood counts and urinalyses when initiating therapy and at monthly intervals for several mo to monitor for blood dyscrasias; discontinue use if skin rash appears and do not resume use if rash is exfoliative, bullous, or purpuric; after too-rapid IV administrations death from cardiac arrest may occur, which is sometimes preceded by marked QRS widening; administer cautiously to patients with acute intermittent porphyria; exercise caution with diabetes, as it may raise blood sugar levels; discontinue drug if hepatic dysfunction occurs

More on Epidural Hematoma

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Multimedia: Epidural Hematoma
References
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References

  1. Borovich B, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg. Jul 1985;63(1):30-4. [Medline].

  2. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24 Suppl 1:S7-13. [Medline]. [Full Text].

  3. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. II. Hyperosmolar therapy. J Neurotrauma. 2007;24 Suppl 1:S14-20. [Medline]. [Full Text].

  4. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. IV. Infection prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S26-31. [Medline]. [Full Text].

  5. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma. 2007;24 Suppl 1:S71-6. [Medline]. [Full Text].

  6. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. XIII. Antiseizure prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S83-6. [Medline]. [Full Text].

  7. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma. 2007;24 Suppl 1:S87-90. [Medline]. [Full Text].

  8. [Guideline] Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. XV. Steroids. J Neurotrauma. 2007;24 Suppl 1:S91-5. [Medline]. [Full Text].

  9. [Guideline] Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24 Suppl 1:S59-64. [Medline]. [Full Text].

  10. [Guideline] Adelson PD, Bratton SL, Carney NA, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents. Chapter 1: Introduction. Pediatr Crit Care Med. Jul 2003;4(3 Suppl):S2-4. [Medline].

  11. [Guideline] American Association of Neurological Surgeons. Guidelines for the management of severe head injury. Congress of Neurological Surgeons:1995.

  12. Bricolo AP, Pasut LM. Extradural hematoma: toward zero mortality. A prospective study. Neurosurgery. Jan 1984;14(1):8-12. [Medline].

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  16. Narayan RK, Wilberger JE Jr, Povlishock JT, eds, et al. Neurotrauma. McGraw Hill Text; 1996.

  17. Roberts J, Hedges J, Fletcher J, ed. Clinical Procedures in Emergency Medicine. 4th ed. WB Saunders Co; 2003.

  18. Schmidek HH, Sweet WH. Operative Neurosurgical Techniques: Indications, Methods, and Results. 4th ed. W B Saunders Co; 2000.

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  20. Temkin NR, Dikmen SS, Wilensky AJ. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. Aug 23 1990;323(8):497-502. [Medline].

  21. Yablon SA. Posttraumatic seizures. Arch Phys Med Rehabil. Sep 1993;74(9):983-1001. [Medline].

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Further Reading

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Keywords

epidural hematoma, epidural hematoma causes, epidural hematoma symptoms, epidural hematoma treatment, traumatic brain injury, EDH, head injury, extradural hemorrhage, blood between the skull and dura mater

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Contributor Information and Disclosures

Author

Daniel D Price, MD, Director of Ultrasound Fellowship, Department of Emergency Medicine, Highland General Hospital, Alameda County Medical Center
Daniel D Price, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Sharon R Wilson, MD, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, University of California at Davis Medical Center
Sharon R Wilson, MD is a member of the following medical societies: American Association of University Women, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Robert M McNamara, MD, FAAEM, Chair and Professor, Department of Emergency Medicine, Temple University School of Medicine
Robert M McNamara, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Association, Pennsylvania Medical Society, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eric L Legome, MD, Chair, Department of Emergency Medicine, St Vincent's Hospital Manhattan; Associate Professor, Department of Emergency Medicine, New York Medical College
Eric L Legome, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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