Epidural Hematoma in Emergency Medicine Workup

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

Laboratory Studies

Perform appropriate laboratory work for associated trauma.

Coagulation abnormalities are a marker of severe head injury. Breakdown of the blood-brain barrier with exposed brain tissue is a potent cause of disseminated intravascular coagulation (DIC).

Next

Imaging Studies

Head CT scan

Immediate unenhanced CT scan is the procedure of choice for diagnosis.

Head CT scan shows location, volume, effect, and other potential intracranial injuries.

Epidural hematoma (EDH) forms an extraaxial, smoothly marginated, lenticular, or biconvex homogenous density.

EDH rarely crosses the suture line because the dura is attached more firmly to the skull at sutures.

Focal isodense or hypodense zones within EDH indicate active bleeding.

Irregular hypodense swirling indicates active bleeding in the majority of patients.

Air in acute EDH suggests fracture of sinuses or mastoid air cells.

At surgery or autopsy, 20% of patients have blood in both epidural and subdural spaces.

Previous
Next

Other Tests

Cervical spine evaluation usually is necessary because of the risk of neck injury associated with EDH.

Previous
Next

Procedures

Perform burr hole(s) if the following occur:

  • Patient is herniating
  • All other treatments prove insufficient
  • Neurosurgery is unavailable for urgent consultation
  • Trephination (or placement of a Burr hole) should ideally be performed if possible by the consulting neurosurgeon at the receiving trauma center
  • Air or ground medical transport is prolonged

Burr hole procedure includes the following:

  • Drill hole adjacent to, but not over, skull fracture or in the area located by CT scan.
  • In the absence of CT scan, place a burr hole on the side of the dilated pupil, 2 finger widths anterior to tragus of ear and 3 finger widths above.
Previous
Proceed to Treatment & Management
 
 
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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.