Epidural Hematoma in Emergency Medicine Treatment & Management

  • Author: Daniel D Price, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Nov 3, 2010
 

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.

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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.

In a small case series, ED skull trephination before transfer of patients with CT-proven epidural hematoma (EDH) and anisocoria resulted in uniformly good outcomes without complications.[2] Time to relief of intracranial pressure was significantly shorter with trephination than without.

Several treatment guidelines on various aspects of traumatic brain injury are available from the Brain Trauma Foundation.[3, 4, 5, 6, 7, 8, 9, 10]

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Consultations

Consult a neurosurgeon immediately for EDH evacuation and repair.

Consult a trauma surgeon for other life-threatening injuries.

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Contributor Information and Disclosures
Author

Daniel D Price, MD  Director of International Ultrasound, Department of Emergency Medicine, Alameda County Medical Center, Highland Hospital and Trauma 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Eric L Legome, MD  Chief, Department of Emergency Medicine, Kings County Hospital Center; 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.

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 

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

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. Smith SW, Clark M, Nelson J, Heegaard W, Lufkin KC, Ruiz E. Emergency department skull trephination for epidural hematoma in patients who are awake but deteriorate rapidly. J Emerg Med. Sep 2010;39(3):377-83. [Medline].

  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. I. Blood pressure and oxygenation. J Neurotrauma. 2007;24 Suppl 1:S7-13. [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. II. Hyperosmolar therapy. J Neurotrauma. 2007;24 Suppl 1:S14-20. [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. IV. Infection prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S26-31. [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. XI. Anesthetics, analgesics, and sedatives. J Neurotrauma. 2007;24 Suppl 1:S71-6. [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. XIII. Antiseizure prophylaxis. J Neurotrauma. 2007;24 Suppl 1:S83-6. [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. XIV. Hyperventilation. J Neurotrauma. 2007;24 Suppl 1:S87-90. [Medline]. [Full Text].

  9. [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].

  10. [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].

  11. [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].

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

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

  14. Davis DP, Peay J, Sise MJ, et al. The impact of prehospital endotracheal intubation on outcome in moderate to severe traumatic brain injury. J Trauma. May 2005;58(5):933-9. [Medline].

  15. Ersahin Y, Mutluer S. Air in acute extradural hematomas: report of six cases. Surg Neurol. Jul 1993;40(1):47-50. [Medline].

  16. Grossman RG, Hamilton WJ. Principles of Neurosurgery. 2nd ed. Lippincott Williams & Wilkins Publishers; 1998.

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

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

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

  20. Servadei F. Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien). 1997;139(4):273-8. [Medline].

  21. 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].

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

 
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Right temporal epidural hematoma with midline shift. Patient should be taken immediately to the operating room for neurosurgery. This may require emergent transport to a trauma center or other facility with a neurosurgeon available.
Brain CT scan of 90-year-old man who slipped on a waxed floor. Witnesses reported loss of consciousness followed by a "lucid interval." Patient arrived to ED unconscious. CT scan indicates epidural hematoma. Image courtesy of Dr Dana Stearns, Massachusetts General Hospital.
 
 
 
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