Epidural Hematoma Management in the ED Treatment & Management

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

Perform 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 to patients intubated in the ED. Bag-valve-mask ventilation with good technique may be of greater benefit  than prehospital intubation for brain-injured patients.

Consult a neurosurgeon immediately for EDH evacuation and repair.

Consult a trauma surgeon for other life-threatening injuries.


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 the head of the bed 30° after the spine is cleared, or use the 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 there are clinical signs of increased ICP progress and patients 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. [18] 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. [19, 20, 21, 22, 23, 24, 25, 26]

Transfer to operating room (OR) for epidural hematoma (EDH) evacuation and repair.

Transfer to hospital with a CT scanner and a neurosurgeon.

Consider air transport if a trauma center is distant; timely decompression is critical for a good outcome.

Admit to the neurosurgical ICU after surgery or directly for monitoring. This will likely include ICP, partial pressure of oxygen (PO2), or other intracranial monitoring devices.