Epidural Hematoma Management in the ED Clinical Presentation

Updated: Dec 10, 2021
  • Author: Daniel D Price, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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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 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.




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.