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Author Information Introduction Rate this Article Clinical Differentials Email to a Workup Colleague Treatment Medication Last Updated: March 8, 2006 Get CME/CE for Follow-up article Miscellaneous Synonyms and related keywords: EDH, head injury, blunt trauma, Pictures Bibliography hemorrhage, extradural hemorrhage, blood between the skull and dura mater, epidural hematoma

Epidural Hematoma

AUTHOR INFORMATION

Section 1 of 11

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Author: Daniel D Price, MD, Director, Emergency Hemorrhage Ultrasound Fellowship, Attending Faculty, Department of Emergency Medicine, Alameda County Medical Center - Subdural Hematoma Highland Campus

Subarachnoid

Coauthor(s): Sharon R Wilson, MD, Assistant Professor of Emergency Medicine, Department of Emergency Continuing Education Medicine, University of California at Davis Medical Center Daniel D Price, MD, is a member of the following medical CME available for this topic. Click societies: American College of Emergency Physicians, here to take this and Society for Academic Emergency Medicine CME. Editor(s): Robert M McNamara, MD, FAAEM, Professor of Emergency Medicine, Temple University; Chief, Patient Education Department of Internal Medicine, Section of Emergency Click here for Medicine, Temple University Hospital; Francisco Talavera, patient education. PharmD, PhD, Senior Pharmacy Editor, eMedicine; Eric Legome, MD, Assistant Professor of Emergency Medicine, New York University Medical School; Consulting Staff, Department of Emergency Medicine, Bellevue Hospital

Center, New York University Hospital, Manhattan VA Hospital; John Halamka, MD, Chief Information Officer, CareGroup Healthcare System, Assistant Professor of Medicine, Department of Emergency Medicine, Beth Israel Deaconess Medical Center; Assistant Professor of Medicine, Harvard Medical School; and Rick Kulkarni, MD, Assistant Professor of Medicine, David Geffen UCLA School of Medicine; Director of Informatics, Department of Emergency Medicine, UCLA/Olive View-UCLA Medical Center

Disclosure

INTRODUCTION

Section 2 of 11

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Background: Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped-off dural membrane. The inciting event often is a focused blow to the head, such as that produced by a hammer or baseball bat. In 85-95% of patients, this type of trauma results in an overlying fracture of the skull. Blood vessels in close proximity to the fracture are the sources of the hemorrhage in the formation of an EDH. Because the underlying brain has usually been minimally injured, prognosis is excellent if treated aggressively. Outcome from surgical decompression and repair is related directly to patient's preoperative neurologic condition. Pathophysiology: Approximately 70-80% of EDHs are located in the temporoparietal region where skull fractures cross the path of the middle meningeal artery or its dural branches. Frontal and occipital EDHs each constitute about 10%, with the latter occasionally extending above and below the tentorium. Association of hematoma and skull fracture is less common in young children because of calvarial plasticity. EDHs are usually arterial in origin but result from venous

bleeding in one third of patients. Occasionally, torn venous sinuses cause EDH, particularly in the parietal-occipital region or posterior fossa. These injuries tend to be smaller and associated with a more benign course. Usually, venous EDHs only form with a depressed skull fracture, which strips the dura from the bone and, thus, creates a space for blood to accumulate. In certain patients, especially those with delayed presentations, venous EDHs are treated nonsurgically. Expanding high-volume EDHs can produce a midline shift and subfalcine herniation of the brain. Compressed cerebral tissue can impinge on the third cranial nerve, resulting in ipsilateral pupillary dilation and contralateral hemiparesis or extensor motor response. EDHs are usually stable, attaining maximum size within minutes of injury; however, Borovich demonstrated progression of EDH in 9% of patients during the first 24 hours. Rebleeding or continuous oozing presumably causes this progression. An EDH can occasionally run a more chronic course and is detected only days after injury. Frequency:

In the US: EDH occurs in 1-2% of all head trauma cases and in about 10% of patients who present with traumatic coma.

Mortality/Morbidity:

Reported mortality rates range from 5-43%. Higher rates are associated with the following: o Advanced age o Intradural lesions o Temporal location o Increased hematoma volume o Rapid clinical progression o Pupillary abnormalities o Increased intracranial pressure (ICP) o Lower Glasgow coma scale (GCS) Mortality rates are essentially nil for patients not in coma preoperatively and approximately 10% for obtunded patients and 20% for patients in deep coma.

Age:

Patients younger than 5 years and older than 55 years have an increased mortality rate. Patients younger than 20 years account for 60% of EDHs. EDH is uncommon in elderly patients because the dura is strongly adhered to the inner table of the skull. In case series of EDH, fewer than 10% of patients are older than 50 years.

CLINICAL

Section 3 of 11

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History:

Fewer than 20% of patients demonstrate the classic presentation of a lucid interval between the initial trauma and subsequent neurological deterioration. Following injury, the patient may or may not lose consciousness. If he or she becomes unconscious, the patient may awaken or remain unconscious. Severe headache Vomiting Seizure Patients with posterior fossa EDH may have a dramatic delayed deterioration. The patient can be conscious and talking and a minute later apneic, comatose, and minutes from death.

Physical:

Cushing response, consisting of the following, can indicate increased ICP:

o o o

Hypertension Bradycardia Bradypnea

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. Classic triad indicating transtentorial herniation consists of the following:
o o o

Coma Fixed and dilated pupil(s) Decerebrate posturing

Hemiplegia contralateral to injury with herniation may be observed.

Causes:

EDH results from traumatic head injury, usually with an associated skull fracture and arterial laceration.
Section 4 of 11

DIFFERENTIALS

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Subarachnoid Hemorrhage Subdural Hematoma

Other Problems to be Considered: Cerebral contusion Diffuse axonal injury

WORKUP

Section 5 of 11

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Lab Studies:

Perform appropriate laboratory work for associated trauma. Coagulation abnormalities are a marker of severe head injury. Breakdown of the blood-brain barrier with exposed brain tissue is a potent cause of disseminated intravascular coagulation (DIC).

Imaging Studies:

Head CT scan
o

Immediate unenhanced CT scan is the procedure of choice for diagnosis. Head CT scan shows location, volume, effect, and other potential intracranial injuries. EDH forms an extraaxial, smoothly marginated, lenticular, or biconvex homogenous density. EDH rarely crosses the suture line because the dura is attached more firmly to the skull at sutures. Focal isodense or hypodense zones within EDH indicate active bleeding. Irregular hypodense swirling indicates active bleeding in the majority of patients. Air in acute EDH suggests fracture of sinuses or mastoid air cells. At surgery or autopsy, 20% of patients have blood in both epidural and subdural spaces.

Other Tests:

Cervical spine evaluation usually is necessary because of the risk of neck injury associated with EDH.

Procedures:

Perform burr hole(s) if the following occur:

o o o o

Patient is herniating All other treatments prove insufficient Neurosurgery is unavailable for urgent consultation Trephination (or placement of a Burr hole) should ideally be performed if possible by the consulting neurosurgeon at the receiving trauma center Air or ground medical transport is prolonged

Burr hole procedure includes the following:

o

Drill hole adjacent to, but not over, skull fracture or in the area located by CT scan. In the absence of CT scan, place a burr hole on the side of the dilated pupil, 2 finger widths anterior to tragus of ear and 3 finger widths above.
Section 6 of 11

TREATMENT

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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. Intubation, sedation, and neuromuscular blockade per protocol.
o

There is some suggestion of increased mortality with prehospital intubation in retrospective reviews of trauma patients with moderate-to-severe head injury compared with patients intubated in the ED. Bag-valve-mask ventilation with good technique may be of more benefit to brain injured patients than prehospital

intubation. 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 head of the bed 30 after the spine is cleared, or use 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 3035 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 clinical signs of increased ICP progress and 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.

Consultations:

Consult a neurosurgeon immediately for EDH evacuation and repair. Consult a trauma surgeon for other life-threatening injuries.

MEDICATION

Section 7 of 11

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Use RSI when intubating to minimize rises in ICP and catecholamine release. Etomidate, when used as RSI sedating agent, maintains blood pressure, lowers ICP and brain metabolism, and has rapid onset and brief duration. Thiopental is not recommended because of its predictable effect in lowering blood pressure, the leading cause of secondary brain injury. Mannitol osmotically reduces ICP and improves blood flow. Phenytoin provides prophylaxis against early posttraumatic seizure. Once the patient has received adequate fluids, pressors such as norepinephrine can be used to maintain MAP >90 mm Hg.

Drug Category: Osmotic diuretic -- Osmotically reduces brain edema

and ICP and reduces blood viscosity, improving cerebral blood flow and oxygen delivery. Prior to ICP monitoring, use only for signs of herniation or progressive neurological deterioration. Hypovolemia should be avoided by replacing fluids (urine monitoring with placement of a bladder catheter is essential). Intermittent boluses may be more effective than continuous infusion. Mannitol (Osmitrol) -- Keeps serum osmolality <320 mOsm to prevent renal failure. Maintain euvolemia with adequate IV fluid replacement. Foley catheter is essential. 0.25-1 g/kg IV q30-60min Administer by weight as in adults

Drug Name Adult Dose Pediatric Dose

Documented hypersensitivity; anuria; severe pulmonary congestion; severe dehydration; Contraindications active intracranial bleeding; progressive renal damage; progressive heart failure; SBP <90 mm Hg Interactions Pregnancy None reported C - Safety for use during pregnancy has not been established. Large crystals may form in a cold solution; carefully evaluate cardiovascular status before rapid administration, as sudden increase in extracellular fluid may lead to fulminating CHF; if blood is coadministered, add at least 20 mEq of sodium chloride to each L of mannitol solution

Precautions

to avoid pseudoagglutination; do not administer electrolyte-free mannitol solutions with blood

Drug Category: Antiepileptic -- Prevents early posttraumatic seizure,

which can increase ICP and neurotransmitter release as well as alter blood pressure and oxygen delivery. Phenytoin (Dilantin) -- DOC for seizure prophylaxis. Fosphenytoin allows more rapid infusion and fewer side effects. If actively seizing, coadminister benzodiazepine. 17 mg/kg IV; mix in NS (precipitates in D5W); infuse no faster than 50 mg/min Administer by weight as in adults

Drug Name

Adult Dose Pediatric Dose

Documented hypersensitivity; because of effects on ventricular automaticity, do not use in Contraindications sinoatrial block, sinus bradycardia, second- and third-degree AV block, or in patients with Adams-Stokes syndrome Increased toxicity with amiodarone, benzodiazepines, chloramphenicol, cimetidine, fluconazole, isoniazid, metronidazole, miconazole, phenylbutazone, succinimides, sulfonamides, omeprazole, phenacemide, disulfiram, ethanol (acute ingestion), trimethoprim, valproic acid; effects may decrease when taken concurrently with barbiturates, diazoxide, ethanol (chronic ingestion), rifampin, antacids, charcoal, carbamazepine, theophylline, sucralfate; may decrease effects of acetaminophen, corticosteroids, dicumarol, disopyramide, doxycycline, estrogens, haloperidol, amiodarone, carbamazepine, cardiac glycosides, quinidine, theophylline, methadone, metyrapone, mexiletine, oral contraceptives, valproic acid D - Unsafe in pregnancy Administer slowly (50 mg/min) to avoid hypotension; avoid extravasation; perform blood counts and urinalyses when initiating therapy and at monthly intervals for several mo to monitor for blood dyscrasias; discontinue use if skin rash appears and do not resume use if rash

Interactions

Pregnancy

Precautions

is exfoliative, bullous, or purpuric; after too-rapid IV administrations death from cardiac arrest may occur, which is sometimes preceded by marked QRS widening; administer cautiously to patients with acute intermittent porphyria; exercise caution with diabetes, as it may raise blood sugar levels; discontinue drug if hepatic dysfunction occurs FOLLOW-UP
Section 8 of 11

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Further Inpatient Care:

Transfer to operating room (OR) for EDH evacuation and repair. Admit to neurosurgical ICU after surgery or directly for monitoring. This will likely include ICP, partial pressure oxygen (PO2), or other intracranial monitoring devices. Repeat CT scan in the event of clinical deterioration.

Transfer:

Transfer to hospital with a CT scanner and neurosurgeon. Consider air transport if a trauma center is distant; timely decompression is critical for a good outcome.

Deterrence/Prevention:

Encourage use of seat belts and car seats. Advocate helmets for bicycling, skateboarding, snowboarding, rollerblading, and horse and motorcycle riding.

Complications:

Neurobehavioral changes: Postconcussive syndrome can last hours to months (see Postconcussive Syndrome). Vegetative state Death

Prognosis:

Mortality rates are essentially nil for patients not in coma preoperatively and approximately 10% for obtunded patients and 20% for patients in deep coma. If treated early, prognosis usually is excellent, because the underlying brain injury generally is limited.
Section 9 of 11

MISCELLANEOUS

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Medical/Legal Pitfalls:

Failure to consider diagnosis, especially in a conscious patient with normal pupils Failure to transfer expeditiously to a trauma center with a neurosurgeon (air medical transport may be warranted) Failure to diagnose EDH in a patient with altered mental status (instead naming alcohol or another intoxicant as the cause) Failure to perform frequent routine neurologic checks in patients who are being observed rather than sent for CT scan

Special Concerns:

Pediatric patients
o o

Pediatric patients may not fracture the skull. Pediatric patients have lower mortality rates, except in infants. Guidelines for managing pediatric traumatic brain injury were published in 2003. They reflect adult guidelines with the exceptions of age-appropriate blood pressures and cerebral perfusion pressure, and endorsement of the use of hypertonic saline for control of increased ICP.

Geriatric patients
o o o

EDH is more likely to occur with a fall. Overall, EDH is much less common in older patients. Subdural hematoma (SDH) is more common than EDH in

elderly patients with intracranial hematoma. Brain atrophy stretches bridging veins.
o

Elderly patients have higher mortality rates.

Section 10 of 11

PICTURES

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Caption: Picture 1. 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. View Full Size Image

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Picture Type: CT Caption: Picture 2. 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. View Full Size Image

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Picture Type: CT BIBLIOGRAPHY

Section 11 of 11

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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[Medline]. American Association of Neurological Surgeons: Guidelines for the management of severe head injury. Congress of Neurological Surgeons: 1995. Borovich B, Braun J, Guilburd JN, et al: Delayed onset of traumatic extradural hematoma. J Neurosurg 1985 Jul; 63(1): 30-4[Medline]. Brain Trauma Foundation: Guidelines for the management of severe traumatic brain injury: Cerebral perfusion pressure. 2000. Bricolo AP, Pasut LM: Extradural hematoma: toward zero mortality. A prospective study. Neurosurgery 1984 Jan; 14(1): 8-12[Medline]. 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[Medline]. Ersahin Y, Mutluer S: Air in acute extradural hematomas: report of six cases. Surg Neurol 1993 Jul; 40(1): 47-50[Medline]. 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. 2000; W B Saunders Co. Servadei F: Prognostic factors in severely head injured adult patients with epidural haematoma's. Acta Neurochir (Wien) 1997; 139(4): 273-8[Medline]. 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[Medline]. Yablon SA: Posttraumatic seizures. Arch Phys Med Rehabil 1993 Sep; 74(9): 983-1001[Medline].
NOTE:

Medicine is a constantly changing science and not all therapies are clearly established. New research changes drug and treatment therapies daily. The authors, editors, and publisher of this journal have used their best efforts to provide information that is up-to-date and accurate and is generally accepted within medical standards at the time of publication. However, as medical science is constantly changing and human error is always possible, the authors, editors, and publisher or any other party involved with the publication of this article do not warrant the information in this article is accurate or complete, nor are they responsible for omissions or errors in the article or for the results of using this information. The reader should confirm the information in this article from other sources prior to use. In particular, all drug doses, indications, and contraindications should be confirmed in the package insert. FULL DISCLAIMER

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