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epidural hematomaExtradural hematoma Neurology A medical emergency in which blood accumulates in the epidural space due to blood leaking from the middle meningeal artery, resulting in compression of the brain/dura mater; sans evacuation, tentorial herniation ensues, followed by a consult with the grim reaper. See Subdural hematoma.
ex·tra·du·ral hem·or·rhage(eks'tră-dūr'ăl hem'ŏr-ăj)
Synonym(s): epidural hematoma, extradural haemorrhage.
|Mean LOS:||6.8 days|
|Description:||MEDICAL: Nonspecific Cerebrovascular Disorders With Major CC|
|Mean LOS:||11.5 days|
|Description:||SURGICAL: Craniotomy for Multiple Significant Trauma|
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 is categorized as a focal brain injury, and it accounts for approximately 50% of all head injuries and 60% of the mortality rate in head-injured patients. 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. If the hematoma is evacuated and bleeding is controlled promptly, the patient’s prognosis is good. Mortality rates range from 5% to 30%.
Generally, head trauma 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.
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. The injury 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.
Although many vascular problems are related to trauma, vascular malformations and coagulopathies can be familial and can lead to spontaneous epidural hematomas.
Gender, ethnic/racial, and life span considerations
Head injury is the leading cause of all trauma-related deaths. Most head injuries 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. Whites have a death rate 40% higher from MVCs than blacks/African Americans in the 15- to 34-year-old age group. Some experts suggest that the pediatric population may have improved neurological outcomes after head injuries than adults. Epidural hematoma is relatively uncommon in elderly patients because, as people age, the dura is strongly adhered to the skull.
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.
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, photophobia, nausea, vomiting, dizziness, convulsions, decreased respirations, or progressive insensitivity to pain (obtundity). 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.
The most common symptoms are headache, nausea/vomiting, 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, 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’s eyes), subscleral hemorrhage, retroauricular ecchymosis (Battle’s 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. 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.
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.
|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, magnetic resonance imaging
Primary nursing diagnosis
DiagnosisIneffective airway clearance related to hypoventilation or airway obstruction
OutcomesRespiratory status: Gas exchange; Respiratory status: Ventilation; Comfort level
InterventionsAirway management; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Anxiety reduction; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring
Planning and implementation
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 neurologically assessment 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. The goal of this 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.
|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) 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.
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. 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’s 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
Mayr, R., Troyer, S., Kastenberger, T., Krappinger, D., Rosenberger, R., Obwegeser, A., & El Attal, R. (2012). The impact of coagulopathy on the outcome of traumatic epidural hematoma. Archives of Orthopaedic and Trauma Surgery, 132(10), 1445–1450.
- A retrospective study among 85 patients diagnosed with traumatic epidural hematoma revealed significantly higher rates of severe disability, persistent vegetative state, and mortality among patients with coagulopathy compared to patients without (p < 0.001).
- There were no significant differences in coagulopathy or scores on the Glascow Outcome Scale between patients treated surgically or nonsurgically.
- Trauma history, description of the event, time elapsed since the event, whether or not the patient had a loss of consciousness and, if so, for how long
- Adequacy of airway, breathing, circulation; serial vital signs
- Appearance, bruising or lacerations, drainage from the nose or ears
- Physical findings related to the site of head injury: Neurological assessment, presence of accompanying symptoms, presence of complications (decreased level of consciousness, unequal pupils, loss of strength and movement, confusion or agitation, nausea and vomiting), CPP, ICP
- Signs of complications: Seizure activity, infection (fever, purulent discharge from any wounds), aspiration pneumonia (shortness of breath, pulmonary congestion, fever, productive cough), increased ICP
- Response to surgery: Stabilizations of vital signs, changes in neurological status
- Response to medications used to control pain and increase ICP
Discharge and home healthcare guidelines
Review with the patient and family proper care techniques for wounds and lacerations. Discuss the recommended activity level and explain rehabilitative exercises. Teach the patient and family to recognize symptoms of infection or a deteriorating level of consciousness and stress the need to contact the physician if such signs or symptoms appear. Teach the patient the purpose; dosage; schedule; precautions; and potential side effects, interactions, and adverse reactions of all prescribed medications. Review with the patient and family all follow-up appointments that have been arranged. Review with the patient and family information regarding the use of safety restraints.