eMedicine Specialties > Emergency Medicine > Trauma & Orthopedics

Subdural Hematoma: Treatment & Medication

Author: Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Contributor Information and Disclosures

Updated: Oct 30, 2009

Treatment

Emergency Department Care

  • Consider endotracheal intubation when GCS score is less than 12 or other indications are present; this guarantees airway protection during the diagnostic workup.
  • Obtain an immediate head CT scan in patients with head trauma who experienced clear loss of consciousness, are symptomatic, are disoriented/amnestic, or have any focal neurologic signs.
  • Elevate the head of the bed to 30 degrees and make sure that the head and neck are maintained in a midline position to optimize venous outflow from the brain.
  • Hyperventilation to a target pCO 2 of 30 mm Hg can reduce ICP in the short term though pCO 2 less than 25 mm Hg is strongly discouraged.
  • Burr holes are a temporizing option when rapid demise is associated with severe head trauma, especially if a herniation syndrome is clinically evident.2
    • Burr holes can guide surgical therapy when head CT imaging is unavailable.
    • Begin on the side of the (first) dilated pupil.
    • Generally, because the lesion represents clotted blood, the burr hole is not curative, and emergent craniotomy is necessary.

Consultations

When a patient who experienced head trauma presents with a GCS score less than 12, consider immediate neurosurgical consultation while stabilizing and diagnostic maneuvers are in progress.

  • Small, asymptomatic, acute SDHs may be managed by observation, serial examinations, and serial CT scanning.
  • Patients with focal findings, neurologic worsening, hematoma greater than 1 cm thick, midline displacement/shift greater than 5 mm, or increased intracranial or posterior fossa pressure require operative intervention.3
  • The usual treatment for acute SDH is craniotomy and evacuation by a neurosurgeon.4
    • After making a large cranial flap, open the dura.
    • Remove the clot with suction, cup forceps, and/or irrigation. Identify and control bleeding sites.

Medication

  • Glucocorticoids are not indicated for head trauma.
  • Intravenous mannitol (0.25 g/kg) may be used to decrease ICP.

More on Subdural Hematoma

Overview: Subdural Hematoma
Differential Diagnoses & Workup: Subdural Hematoma
Treatment & Medication: Subdural Hematoma
Follow-up: Subdural Hematoma
Multimedia: Subdural Hematoma
References
Further Reading
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References

  1. Cohen M, Scheimberg I. Subdural haemorrhage and child maltreatment. Lancet. Apr 4 2009;373(9670):1173; author reply 1173-4. [Medline].

  2. Zumofen D, Regli L, Levivier M, Krayenbühl N. Chronic subdural hematomas treated by burr hole trepanation and a subperiostal drainage system. Neurosurgery. Jun 2009;64(6):1116-21; discussion 1121-2. [Medline].

  3. Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW. Surgical management of acute subdural hematomas. Neurosurgery. Mar 2006;58(3 Suppl):S16-24; discussion Si-iv. [Medline].

  4. Mobbs R, Khong P. Endoscopic-assisted evacuation of subdural collections. J Clin Neurosci. May 2009;16(5):701-4. [Medline].

  5. Narita E, Maruya J, Nishimaki K, Heianna J, Miyauchi T, Nakahata J, et al. [Case of infected subdural hematoma diagnosed by diffusion-weighted imaging]. Brain Nerve. Mar 2009;61(3):319-23. [Medline].

  6. Bell RS, Neal CJ, Lettieri CJ, Armonda RA. Severe Traumatic Brain Injury: Evolution and Current Surgical Management. Medscape. Available at http://cme.medscape.com/viewarticle/575753. Accessed June 24, 2008.

  7. Buntain BL. Craniocerebral injuries. In: Management of Pediatric Trauma. WB Saunders; 1995:177-88.

  8. Eijkenboom M, Gerlach I, Barker A, et al. Chronic cognitive effects of bilateral subdural haematomas in the rat. Neuroscience. 2004;124(3):523-33. [Medline].

  9. Rockswold GL, Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 4th ed. McGraw-Hill; 1996:1142.

  10. Saito T, Kushi H, Makino K, Hayashi N. The risk factors for the occurrence of acute brain swelling in acute subdural hematoma. Acta Neurochir Suppl. 2003;86:351-4. [Medline].

  11. Valadka AB, Narayan RK. Injury to the cranium. In: Trauma. 3rd ed. 1996:267-78.

  12. Wind JJ, Leiphart JW. Images in clinical medicine. Bilateral subacute subdural hematomas. N Engl J Med. Apr 23 2009;360(17):e23. [Medline].

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Further Reading

Clinical guidelines

Surgical management of acute subdural hematomas.
Brain Trauma Foundation - Disease Specific Society. 2006 Mar. 9 pages. NGC:005061

ACR Appropriateness Criteria® head trauma.
American College of Radiology - Medical Specialty Society. 1996 (revised 2006). 12 pages. [NGC Update Pending] NGC:005118

Clinical trials

Teen Online Problem Solving (TOPS) - An Online Intervention Following TBI

Internet-Based Treatment for Children With Traumatic Brain Injuries & Their Families: Counselor Assisted Problem Solving (CAPS)

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Contributor Information and Disclosures

Author

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Richard S Krause, MD, Senior Faculty, Department of Emergency Medicine, State University of New York at Buffalo School of Medicine
Richard S Krause, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, 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

David B Levy, DO, FACEP, FAAEM, Chairman, Department of Emergency Medicine, St Elizabeth Health Center; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine
David B Levy, DO, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American Medical Informatics Association, 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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