ACUTE EPIDURAL HEMATOMA

Background Epidural hematoma (ie, accumulation of blood in the potential space between dura and bone) may be intracranial (EDH) or spinal (SEDH) (see the image below). Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries and 5-15% of patients with fatal head injuries. Intracranial epidural hematoma is considered to be the most serious complication of head injury, requiring immediate diagnosis and surgical intervention. Intracranial epidural hematoma may be acute (58%), subacute (31%), or chronic (11%). Spinal epidural hematoma may also be traumatic, though it may occur spontaneously. History Epidural hematoma should be suspected in any individual who sustains head trauma. Although classically associated with a lucid interval between the initial loss of consciousness at the time of impact and a delayed decline in mental status (10-33% of cases), alterations in the level of consciousness may have a variable presentation. Posterior fossa epidural hematoma may exhibit a rapid and delayed progression from minimal symptoms to even death within minutes.
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Symptoms of epidural hematoma include the following: Headache Nausea/vomiting Seizures Focal neurologic deficits (eg, visual field cuts, aphasia, weakness, numbness)

Physical The physical examination should include a thorough evaluation for evidence of traumatic sequelae and associated neurological deficits, including the following: Bradycardia and/or hypertension indicative of elevated intracranial pressure Skull fractures, hematomas, or lacerations Cerebrospinal fluid (CSF) otorrhea or rhinorrhea resulting from skull fracture with disruption of the dura Instability of the vertebral column Facial nerve injury Weakness (eg, contralateral hemiparesis due to compression of the cerebral peduncle) Other focal neurological deficits (eg, aphasia, visual field defects, numbness, ataxia)

Treatment:
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 2832 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. 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.

CLIENTS PROFILE: Name: Wilmer P. Tarape Age: 42 Sex: Male Date of Birth: January 15, 1969 Nationality: Filipino Religion: Roman Catolic Currently Living: Barangay Maloong, Catbalogan, Samar Language: Ilokano, Tagalog Date Admitted: July 12, 2011, 1628H Diagnosis: Acute Epidural Hematoma 2 to VA Chief Complaints: Bilateral lower extremities weakness Previous Hospitalization: Craniotomy (June 2010); Cranioplasty (July 2011) Medicines taken: a. b. c. d. e. Celecoxib Ascorbic Acid Citicoline Simvastatin Vitamin B Complex