Sections

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

Treatment

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.

Medication

Khairat A, Waseem M. Epidural Hematoma. 2021 Jan. [QxMD MEDLINE Link]. [Full Text].
Dadashi E, Entezami P, De Tommasi C. Epidural hematoma from impact while zorbing. Brain Inj. 2021 Sep 6. 1-2. [QxMD MEDLINE Link].
Bir SC, Maiti TK, Ambekar S, Nanda A. Incidence, hospital costs and in-hospital mortality rates of epidural hematoma in the United States. Clin Neurol Neurosurg. 2015 Nov. 138:99-103. [QxMD MEDLINE Link].
Okuyama Y, Uchida HA, Iwahori T, et al. The relationship between repeated measurement of casual and 24-h urinary sodium-to-potassium ratio in patients with chronic kidney disease. J Hum Hypertens. 2019 Apr. 33 (4):286-297. [QxMD MEDLINE Link].
Binder H, Majdan M, Tiefenboeck TM, Fochtmann A, Michel M, Hajdu S, et al. Management and outcome of traumatic epidural hematoma in 41 infants and children from a single center. Orthop Traumatol Surg Res. 2016 Oct. 102 (6):769-74. [QxMD MEDLINE Link].
Pereira EL, Rodrigues DB, Lima LO, Sawada LA, Hermes Mde N Jr. Bilateral assymetric epidural hematoma. Surg Neurol Int. 2015 Jan 30. 6:14. [QxMD MEDLINE Link].
Paiva WS, Andrade AF, Alves AC, Ribeiro IN, Teixeira MJ. Bilateral acute epidural hematoma with good outcome. J Clin Diagn Res. 2013 Nov. 7 (11):2594-5. [QxMD MEDLINE Link].
Gutowski P, Meier U, Rohde V, Lemcke J, von der Brelie C. Clinical Outcome of Epidural Hematoma Treated Surgically in the Era of Modern Resuscitation and Trauma Care. World Neurosurg. 2018 Oct. 118:e166-e174. [QxMD MEDLINE Link].
Svoboda N, Tyll T, Beneš V, Netuka D. Epidural hematoma - benign or potentially malignant disease?. Rozhl Chir. Spring 2018. 97 (6):267-272. [QxMD MEDLINE Link].
Khairat A, Waseem M. Epidural Hematoma. 2021 Jan. [QxMD MEDLINE Link]. [Full Text].
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].
Borovich B, Braun J, Guilburd JN, et al. Delayed onset of traumatic extradural hematoma. J Neurosurg. 1985 Jul. 63(1):30-4. [QxMD MEDLINE Link].
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].
Ordookhanian C, Kaloostian PE. Trauma-induced Acute Epidural Hematoma: The Rising Sun in a Progressively Lethargic Man. Cureus. 2018 Aug 20. 10 (8):e3162. [QxMD MEDLINE Link].
Flaherty BF, Loya J, Alexander MD, Pandit R, Ha BY, Torres RA, et al. Utility of clinical and radiographic findings in the management of traumatic epidural hematoma. Pediatr Neurosurg. 2013. 49(4):208-14. [QxMD MEDLINE Link].
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].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
[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. [QxMD MEDLINE Link]. [Full Text].
Nelson JA. Local skull trephination before transfer is associated with favorable outcomes in cerebral herniation from epidural hematoma. Acad Emerg Med. 2011 Jan. 18(1):78-85. [QxMD MEDLINE Link].
Irie F, Le Brocque R, Kenardy J, Bellamy N, Tetsworth K, Pollard C. Epidemiology of traumatic epidural hematoma in young age. J Trauma. 2011 Oct. 71(4):847-53. [QxMD MEDLINE Link].
[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. 2003 Jul. 4(3 Suppl):S2-4. [QxMD MEDLINE Link].
[Guideline] American Association of Neurological Surgeons. Guidelines for the management of severe head injury. Congress of Neurological Surgeons:1995.
Bricolo AP, Pasut LM. Extradural hematoma: toward zero mortality. A prospective study. Neurosurgery. 1984 Jan. 14(1):8-12. [QxMD MEDLINE Link].
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. 2005 May. 58(5):933-9. [QxMD MEDLINE Link].
Ersahin Y, Mutluer S. Air in acute extradural hematomas: report of six cases. Surg Neurol. 1993 Jul. 40(1):47-50. [QxMD MEDLINE Link].
Grossman RG, Hamilton WJ. Principles of Neurosurgery. 2nd ed. Lippincott Williams & Wilkins Publishers; 1998.
Narayan RK, Wilberger JE Jr, Povlishock JT, eds, et al. Neurotrauma. McGraw Hill Text; 1996.
Roberts J, Hedges J, Fletcher J, ed. Clinical Procedures in Emergency Medicine. 4th ed. WB Saunders Co; 2003.
Schmidek HH, Sweet WH. Operative Neurosurgical Techniques: Indications, Methods, and Results. 4th ed. W B Saunders Co; 2000.
Servadei F. Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien). 1997. 139(4):273-8. [QxMD MEDLINE Link].
Temkin NR, Dikmen SS, Wilensky AJ. A randomized, double-blind study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med. 1990 Aug 23. 323(8):497-502. [QxMD MEDLINE Link].
Yablon SA. Posttraumatic seizures. Arch Phys Med Rehabil. 1993 Sep. 74(9):983-1001. [QxMD MEDLINE Link].

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 Treatment & Management

Prehospital Care

Emergency Department Care

References

Tables

Contributor Information and Disclosures

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