Epidural Hematoma Treatment & Management

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Epidural Hematoma Treatment & Management

News Reference Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more... Education MEDLINE Updated: Jul 10, 2012

Medical Care
Initial resuscitation efforts should include assessment and stabilization of airway patency, breathing, and circulation. A thorough trauma evaluation is mandatory, including inspection for skull fractures and appreciation of the force and location of impact. Immobilization of the spine should be followed by emergent transfer of the patient to the nearest level I trauma center supported with neurosurgical consultation. Triage and initial management of a patient with epidural hematoma may be tailored to the degree of neurological impairment at presentation. Alert patients may be evaluated with a CT scan following a brief neurologic examination. A patient with a small epidural hematoma may be treated conservatively, though close observation is advised, as delayed, yet sudden, neurological deterioration may occur. Trauma patients may require diagnostic peritoneal lavage and radiographs of the chest, pelvis, and cervical spine. While neurosurgical consultation is requested, administer intravenous fluids to maintain euvolemia and to provide adequate cerebral perfusion pressure. Patients with elevated intracranial pressure may be treated with osmotic diuretics and hyperventilation, with elevation of the head of the bed at an angle of 30 degrees. Patients who are intubated may be hyperventilated with intermittent mandatory ventilation at a rate of 16-20 breaths per minute and tidal volume of 10-12 mL/kg. A carbon dioxide partial pressure of 28-32 mm Hg is ideal, as severe hypocapnia (< 25 mm Hg) may induce cerebral vasoconstriction and ischemia. Coagulopathy or persistent bleeding may require administration of vitamin K, protamine sulfate, fresh frozen plasma, platelet transfusions, or clotting factor concentrates.

Surgical Care
Although several recent reports have described successful conservative management of epidural hematoma, surgical evacuation constitutes definitive treatment of this condition (see the image below). Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the bone and, occasionally, epidural drains are employed for as long as 24 hours.

CT scanning performed before and after surgical evacuation of an intracranial epidural hematoma.

Minimally invasive surgical procedures, including the use of burr holes and negative pressure drainage, may be used in selected cases. Novel therapeutic approaches Endovascular embolization to minimize bleeding during the acute stage

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Epidural Hematoma Treatment & Management

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Thrombolytic evacuation using closed suction drain

Epidural Hematoma Treatment & Management Neurosurgeon (for potential emergent evacuation of the hematoma)
Neurologist Author: David Sspecialist Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more... Rehabilitation Updated: Jul 10, 2012

Consultations

Diet

The hypermetabolic and catabolic phenomena associated with severe head injury necessitate caloric supplementation. Initiate enteral feedings as soon as possible.

Activity
Patients who are treated conservatively should undergo close observation and should avoid strenuous activity. Inpatients should remain on bedrest during the initial phase; this can be followed by a progressive increase in activity.

Contributor Information and Disclosures

Author David S Liebeskind, MD Professor of Neurology, Program Director, Vascular Neurology Residency Program, University of California, Los Angeles, David Geffen School of Medicine; Neurology Director, Stroke Imaging Program, Co-Medical Director, Cerebral Blood Flow Laboratory, Associate Neurology Director, UCLA Stroke Center David S Liebeskind, MD is a member of the following medical societies: American Academy of Neurology, American Heart Association, American Medical Association, American Society of Neuroimaging, American Society of Neuroradiology, National Stroke Association, and Stroke Council of the American Heart Association Disclosure: Nothing to disclose. Specialty Editor Board Edward L Hogan, MD Professor, Department of Neurology, Medical College of Georgia; Emeritus Professor and Chair, Department of Neurology, Medical University of South Carolina Edward L Hogan, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Neurological Association, American Society for Biochemistry and Molecular Biology, Phi Beta Kappa, Sigma Xi, Society for Neuroscience, and Southern Clinical Neurological Society Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Howard S Kirshner, MD Professor of Neurology, Psychiatry and Hearing and Speech Sciences, Vice Chairman, Department of Neurology, Vanderbilt University School of Medicine; Director, Vanderbilt Stroke Center; Program Director, Stroke Service, Vanderbilt Stallworth Rehabilitation Hospital; Consulting Staff, Department of Neurology, Nashville Veterans Affairs Medical Center Howard S Kirshner, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Neurology, American Heart Association, American Medical Association, American Neurological Association, American Society of Neurorehabilitation, National Stroke Association, Phi Beta Kappa, and Tennessee Medical

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Epidural Hematoma Treatment & Management

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Association Disclosure: Nothing to disclose. Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Epidural Hematoma Treatment & Management Neurosurgery, Tampa General Hospital, University of South Florida College of Medicine Author: David S Liebeskind, MD; Chief Editor: Helmi L Lutsep, MD more... Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Updated: Jul Academy 10, 2012 of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, and American Medical Association Disclosure: UCB Pharma Honoraria Speaking, consulting; Lundbeck Honoraria Speaking, consulting; Cyberonics Honoraria Speaking, consulting; Glaxo Smith Kline Honoraria Speaking, consulting; Pfizer Honoraria Speaking, consulting; Sleepmed/DigiTrace Honoraria Speaking, consulting Chief Editor Helmi L Lutsep, MD Professor and Vice Chair, Department of Neurology, Oregon Health and Science University School of Medicine; Associate Director, Oregon Stroke Center Helmi L Lutsep, MD is a member of the following medical societies: American Academy of Neurology and American Stroke Association Disclosure: Co-Axia Consulting fee Review panel membership; AGA Medical Consulting fee Review panel membership; Concentric Medical Consulting fee Review panel membership

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