History

Fewer than 20% of patients demonstrate the classic presentation of a lucid interval between the initial trauma and subsequent neurologic deterioration. Following injury, the patient may or may not lose consciousness. If he or she becomes unconscious, the patient may awaken or remain unconscious. Other symptoms include severe headache, vomiting, and seizure.

Patients with posterior fossa epidural hematoma (EDH) may have a dramatic delayed deterioration. The patient can be conscious and talking and a minute later can be apneic, comatose, and minutes from death. It is imperative that neurosurgeons closely monitor the patient’s state of consciousness, as a rapid decline serves as a key diagnostic indicator of the need for immediate surgery.^[14]

(See the image below.

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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Physical

Cushing response, consisting of hypertension, bradycardia, and bradypnea, can indicate increased ICP. Level of consciousness may be decreased, with decreased or fluctuating GCS. Contusion, laceration, or bony step-off may be observed in the area of injury. Dilated, sluggish, or fixed pupil(s), bilateral or ipsilateral to injury, suggest increased ICP or herniation.

The classic triad indicating transtentorial herniation consists of the following:

Coma
Fixed and dilated pupil(s)
Decerebrate posturing

Hemiplegia contralateral to injury with herniation may be observed.

Differential Diagnoses

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Kopacz AA, Miears H, Collins RA, Nagy L. Novel Predictive Markers on Computed Tomography for Predicting Early Epidural Hematoma Growth in Pediatric Patients. J Neurosci Rural Pract. 2021 Oct. 12 (4):689-693. [QxMD MEDLINE Link].
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Zhang Y, Li Q, Zhao R, Yang Z, Li Y, Min W, et al. Novel Minimally Invasive Treatment Strategy for Acute Traumatic Epidural Hematoma: Endovascular Embolization Combined with Drainage Surgery and Use of Urokinase. World Neurosurg. 2018 Feb. 110:206-209. [QxMD MEDLINE Link].
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Paiva WS, Andrade AF, Amorim RL, Bor-Seng-Shu E, Gattas G, Neville IS, et al. Computed tomography angiography for detection of middle meningeal artery lesions associated with acute epidural hematomas. Biomed Res Int. 2014. 2014:413916. [QxMD MEDLINE Link]. [Full Text].
Flaherty BF, Moore HE, Riva-Cambrin J, Bratton SL. Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma. Pediatrics. 2018 Sep. 142 (3):[QxMD MEDLINE Link].
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. 2010 Sep. 39(3):377-83. [QxMD MEDLINE Link].
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Media Gallery

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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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, 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 College of Emergency Physicians, Society for Academic Emergency Medicine, American Association of University Women

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Eric L Legome, MD Professor and Chair, Department of Emergency Medicine, Mount Sinai St Lukes and Mount Sinai West; Vice Chair of Academic Affairs, Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai

Eric L Legome, MD is a member of the following medical societies: American College of Emergency Physicians, Eastern Association for the Surgery of Trauma, New York American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

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, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Sections Epidural Hematoma Management in the ED
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
References

Epidural Hematoma Management in the ED Clinical Presentation

History

Physical

References

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