Epidural Hematoma

An intracranial epidural hematoma is a rapidly accumulating mass of blood, usually clotted, or a swelling confined to the space between the skull and the dura mater. It is usually found in the temporoparietal region where a skull fracture will cross the path of the middle meningeal artery or the dural branches. It occurs in approximately 2% of people with traumatic brain injuries (TBIs) and 5% to 15% of people with fatal brain injuries; estimates are that up to 20% to 50% of people die after an epidural hematoma. If an epidural hematoma expands rapidly, such as when the bleeding is arterial in origin, the injury is potentially fatal. The accumulation of blood rapidly displaces brain tissue and can result in cerebral herniation downward into the posterior fossa or toward the midline into the tentorial notch. Skull fractures occur in approximately 90% of adults with an epidural hematoma. If the hematoma is evacuated and bleeding is controlled promptly, the patient's prognosis is good. An epidural hematoma may also occur along the spine.

Generally, TBI involves both a primary injury and a secondary injury. The primary injury results from the initial impact, which causes immediate neurological damage and dysfunction. The secondary injury follows the initial trauma and probably stems from cerebral hypoxia and ischemia, which lead to cerebral edema, increased intracranial pressure (ICP), and brain herniation.

Causes ⬆ ⬇

The injuries that cause the condition are a strong direct force to the head or an acceleration-deceleration force, which can occur in motor vehicle crashes (MVCs), automobile-pedestrian crashes, falls, and assaults. TBI causes a linear fracture of the temporal lobe in many patients. The bone fracture lacerates the middle meningeal artery or veins. Bleeding from these vessels leads to the accumulation of the hematoma within the extradural portion of the skull.

Genetic Considerations ⬆ ⬇

Although many vascular problems are related to trauma, vascular malformations and coagulopathies can be familial and can potentially lead to spontaneous epidural hematomas.

Sex and Life Span Considerations ⬆ ⬇

TBI is the leading cause of all trauma-related deaths. Most are associated with MVCs, which in the 15- to 24-year-old age group are three times more common in males than in females. The age group younger than 20 years accounts for 60% of epidural hematoma occurrence. Some experts suggest that the pediatric population may have improved neurological outcomes after head injuries compared to adults. Epidural hematoma is relatively uncommon in older adults because, as people age, the dura is strongly adhered to the skull.

Health Disparities and Sexual/Gender Minority Health ⬆ ⬇

In recent years, Black persons have been killed in traffic crashes at a rate almost 25% higher than White persons (National Highway Traffic Safety Administration [NHTSA], 2021). Native American persons have the highest rate of MVC injury in the United States, more than twice the rate of Black persons (NHTSA, 2021). Experts have noted that Black and Native American communities tend to be crisscrossed by more dangerous roads than other locations, placing people from those communities at risk for injury. Stark disparities exist with the incidence, management, and rehabilitation of TBI. The Centers for Disease Control and Prevention (CDC) report that Native American children and adults have the highest TBI-related hospitalizations and deaths in the United States. Important health disparities exist in treatment, follow-up, and rehabilitation of TBI. Non-Hispanic Black and Hispanic patients are less likely to receive follow-up care and rehabilitation following TBI and more likely to have poor psychosocial, functional, and employment-related outcomes as compared to non-Hispanic White patients (CDC, 2021).

The CDC reports that in the 20 years since the year 2000, more than 400,000 U.S. service members were diagnosed with TBI, including active military service members and Veterans. Approximately 80% of these injuries occurred when the service members were not deployed. These injuries may result in ongoing symptoms, posttraumatic distress syndrome, and suicidal thoughts. People in correctional or detention facilities, people who experience homelessness, and survivors of intimate partner violence may have long-term consequences from TBI. People with lower incomes and those without health insurance have less access to TBI care, are less likely to receive surgical procedures and cranial monitoring when indicated, are less likely to receive rehabilitation, and are more likely to die in the hospital. Recent work has shown that rural populations have injury mortality rates that are more than twice as high as urban rates. Many factors contribute to these health disparities, including the risk of traffic injury in narrow rural roads, the lack of graded curves and lighted traffic signals on rural highways, and the distance from major trauma centers. Many of the most dangerous occupations, such as mining and agriculture, are found in rural areas and can result in injury, disability, and death. People living in rural areas who experience a TBI have more time to travel to get emergency care, less access to high-level trauma care, and more difficulty accessing TBI services. Sexual and gender minority persons have high risk for dating and interpersonal violence, violence related to bullying, and intentional and unintentional injury; therefore, they are at risk for TBI (Healthy People 2020).

Global Health Considerations ⬆ ⬇

Internationally, falls from heights of less than 5 meters are the leading cause of injury overall, and automobile crashes are the next most frequent cause. Both have the potential to cause an epidural hematoma.

Assessment ⬆ ⬇

ASSESSMENT

History

Obtain a detailed description of the initial injury. Determine if the patient experienced momentary loss of reflexes or momentary arrest of respiration. Be sure to determine if the patient was unconscious at any time and, if so, for how long. Determine if the patient experienced nuchal rigidity, a seizure, photophobia, nausea, vomiting, dizziness, convulsions, decreased respirations, or progressive insensitivity to pain (obtundity). Ask if the individual had urinary or fecal incontinence. Note that approximately one-third of patients with an epidural hematoma have initial unconsciousness followed by a period of lucidity and then subsequent unconsciousness. Some experienced clinicians suggest the initial period of unconsciousness is brought about by a concussion. The patient awakens, only to become unconscious again because of epidural bleeding. Children may be difficult to diagnose; in addition to neck sensitivity, parents may describe irritability or other unspecific symptoms.

Physical Examination

The most common symptoms are headache, nausea and vomiting, seizures, and changes in mental status. The initial evaluation is centered on assessing the airway, breathing, circulation, and disability (neurological status). Exposure (undressing the patient completely) is incorporated as part of the primary survey. The secondary survey, a head-to-toe assessment including vital signs, is then completed.

The initial neurological assessment of the patient includes monitoring vital signs, assessing the level of consciousness, examining pupil size and level of reactivity, and assessment using the Glasgow Coma Scale (GCS), which evaluates eye opening, best verbal response, and best motor response. The neurological signs and symptoms depend on the location, rapidity, and source of bleeding. More than half of patients develop symptoms within the first 6 hours. Common symptoms include pupil dilation, hemiparesis, seizures, and decerebrate posturing (extension). A neurological assessment is repeated at least hourly during the first 24 hours after the injury.

Examine the entire scalp and head for lacerations, abrasions, contusions, or bony abnormalities. Take care to maintain cervical spine immobilization during the examination. Patients may have associated cervical spine injuries or thoracic, abdominal, or extremity trauma. Examine the patient for signs of basilar skull fractures, such as periorbital ecchymosis (raccoon eyes), subscleral hemorrhage, retroauricular ecchymosis (Battle sign), hemotympanum (blood behind the eardrum), and leakage of cerebrospinal fluid from the ears (otorrhea) or nose (rhinorrhea). Gently palpate the facial bones, including the mandible and maxilla, for bony deformities or step-offs. Examine the oral pharynx for lacerations, and check for any loose or fractured teeth.

Ongoing assessments are important throughout the trauma resuscitation and during recovery. Assess the patient's fluid volume status, including hemodynamic, urinary, and central nervous system (CNS) parameters, on an hourly basis until the patient is stabilized. Cardiovascular changes may include bradycardia or hypertension if ICP is elevated. Notify the physician of any early indications that volume status is inadequate, such as delayed capillary refill, tachycardia, or a urinary output less than 0.5 mL/kg per hour. Monitoring urinary specific gravity, serum sodium, potassium, chloride, and osmolarity is helpful in assessing volume status. Infection surveillance is accomplished by assessing temperature curves, white blood cell counts, and the entrance sites of monitoring devices.

Psychosocial

Epidural hematoma is the result of a sudden, unexpected traumatic injury and may alter an individual's ability to cope effectively. The patient may be anxious during intervals of lucidity. Expect parents of children who are injured to feel anxious, fearful, and sometimes guilty. Note if the injury was related to alcohol consumption (approximately 40% to 60% of head injuries occur when the patient has been drinking), and elicit a drinking history from the patient or significant others. Assess the patient for signs of alcohol withdrawal 2 to 14 days after admission.

Diagnostic Highlights

Test	Normal Result	Abnormality With Condition	Explanation
Computed tomography scan	Normal brain structures	Structural abnormalities, including skull fractures, soft tissue abnormalities, hemorrhage, cerebral edema, and shifting brain structures	Provides rapid, accurate diagnostic evaluation of a suspected epidural hematoma
Radiological examination: Skull, chest, and cervical (all cervical vertebrae including C7-T1 junction) spine x-rays with anteroposterior, lateral, and open-mouth view	Normal bone, joint, and soft tissue structure	Accompanying structural abnormalities	If the patient is unconscious, skull, chest, and spinal injuries need to be ruled out

Other Tests: Transcranial Doppler ultrasound and arterial blood gases, complete blood count, coagulation studies, serum drug and alcohol screens, magnetic resonance imaging

Primary Nursing Diagnosis ⬆ ⬇

Diagnosis

DiagnosisIneffective airway clearance related to hypoventilation or airway obstruction as evidenced by reduced chest excursion and/or apnea

Outcomes

OutcomesRespiratory status: Airway patency; Respiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level

Interventions

InterventionsAirway management; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Anxiety reduction; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Planning and Implementation ⬆ ⬇

PLANNING AND IMPLEMENTATION

Collaborative

Endotracheal intubation and mechanical ventilation may be necessary to ensure oxygenation and ventilation and to decrease the risk of pulmonary aspiration. A Pao₂ greater than 100 mm Hg and Paco₂ between 28 and 33 mm Hg can decrease cerebral blood flow and intracranial swelling. If the patient is treated medically, serial neurological assessments are essential so that if neurological deterioration occurs, treatment can be initiated immediately.

The decision to treat surgically as compared to conservative medical treatment generally depends on the size of the hematoma and the severity of symptoms. Surgical evaluation of the clot, control of the hemorrhage, and resection of nonviable brain tissue may be warranted as soon as possible. A Jackson-Pratt drain may be used for 24 to 48 hours to drain the site. Complications include intracranial hypertension, re-accumulation of the clot, intracerebral hemorrhage, and the development of seizures. If surgical evacuation is not possible and the patient has a rapidly deteriorating status, the surgeon may place a burr hole on the same side as a dilated pupil or on the opposite side of motor deficits and the hematoma.

ICP monitoring may be used in patients who have a high probability of developing intracranial hypertension along with osmotic diuretics, hyperventilation, and elevation of the head of the bed. The goal of monitoring is to maintain the ICP at less than 10 mm Hg and the cerebral perfusion pressure (CPP) at greater than 80 mm Hg. Intermittent or continuous draining of cerebrospinal fluid through a ventriculostomy can be used to reduce ICP.

Pharmacologic Highlights

Medication or Drug Class	Dosage	Description	Rationale
Sedatives, analgesics, anesthetics	Varies with drug	Midazolam (Versed); propofol (Diprivan); fentanyl (Sublimaze)	Control intermittent increases in ICP with a resultant decrease in CPP; the drugs are short acting so that they can be temporarily stopped for intermittent neurological assessment
Chemical paralytic agents	Varies with drug	Mivacurium (Mivacron); atracurium (Tracrium); vecuronium (Norcuron)	Neuromuscular blocking agent to provide muscle relaxation is needed to improve oxygenation and ventilation; sedation must accompany paralysis

Other Drugs: Seizure activity can elevate ICP and increase oxygen demand. Phenytoin (Dilantin) or fosphenytoin may be used prophylactically, but the overall effectiveness has yet to be determined. Persistently elevated ICP, despite routine therapeutic interventions, may be managed by inducing a barbiturate coma to reduce the metabolic rate of brain tissue. Pentobarbital is commonly used. Before beginning this therapy, it is critical to determine adequate volume status to prevent hypotension and to ensure adequate tissue perfusion caused by the drug's depressant effect on myocardial contractility. Broad-spectrum antibiotic therapy is used to treat meningitis until culture and sensitivity results are available. Commonly prescribed diuretics (furosemide and mannitol) may be used to assist in managing intracranial hypertension, although their use remains controversial. Fever needs to be treated promptly with acetaminophen. Methylprednisolone may be administered to decrease inflammation, particularly if the spinal cord is involved.

Independent

The highest management priority is maintaining a patent airway, appropriate ventilation and oxygenation, and adequate circulation. Make sure the patient's endotracheal tube is anchored well. If the patient is at risk for self-extubation, use soft restraints. Note the lip level of the endotracheal tube to determine if tube movement occurs. Notify the physician if the patient's Pao₂ drops below 80 mm Hg, Paco₂ exceeds 40 mm Hg, or severe hypocapnia (Paco₂< 25 mm Hg) occurs.

Avoid body temperature elevations and flexing, extending, or rotating the patient's neck to prevent a sudden increase in ICP. Maintain the patient in a normal body alignment to prevent obstruction of venous drainage. Generally, the head of the bed is elevated to reduce ICP. Maintain a quiet, restful environment with minimal stimulation. Time nursing care activities carefully to limit prolonged ICP elevations. When suctioning, hyperventilate the patient beforehand and suction only as long as necessary. When turning the patient, prevent Valsalva maneuver by using a draw sheet to pull the patient up in bed. Instruct the patient not to hold on to the side rails.

Provide support and encouragement to the patient and family. Provide educational tools and teach the patient and family appropriate rehabilitative exercises. Provide diversionary activities appropriate to the patient's mental and physical abilities. Head injury support groups may be helpful. Referrals to clinical nurse specialists, pastoral care staff, and social workers are helpful in developing strategies for support and education.

Evidence-Based Practice and Health Policy

McClung, C., Anshus, J., Anshus, A., & Baker, S. (2020). Bedside craniostomy and serial aspiration with an intraosseous drill/needle to temporize an acute epidural hemorrhage with mass effect. World Neurosurgery, 142, 218–221.

The authors report on a technique for an immediate mechanical intervention using a familiar tool for emergency physicians and trauma surgeons to manage acute epidural bleeding with mass effect. They describe a case study of a 38-year-old male with active extradural hemorrhage and expanding hematoma who was treated at the bedside with an intraosseous drill to perform a craniostomy.
- This procedure allowed for serial aspirations of continued bleeding and immediate management of a large epidural hemorrhage. The technique can be applied by emergency physicians or trauma specialists when neurosurgical consultation is delayed.

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DRG Information ⬇

Introduction ⬆ ⬇