Basics
Description
- Direct skull trauma
- Inward bending of calvarium causes bleeding when dura separates from skull:
- Middle meningeal artery is involved in bleed >50% of time.
- Meningeal vein is involved in 1/3.
- Skull fracture is associated in 75% of cases, less commonly in children.
- >50% have epidural hematoma (EDH) as isolated head injury:
- Most commonly associated with subdural hematoma (SDH) and cerebral contusion
- Classic CT finding is lenticular, unilateral convexity, usually in temporal region.
- It usually does not cross suture lines, but may cross midline.
Etiology
- Accounts for 1.5% of traumatic brain injury (TBI)
- Male/female incidence is 3:1.
- Peak incidence is 2nd-3rd decade of life.
- Motor vehicle accidents (MVAs), assault, and falls are most common causes:
- Of all blunt mechanisms, assault has highest association with intracranial injury requiring neurosurgical intervention.
- Uncommon in very young (<5 yr) or elderly patients
- Mortality is 12% and is related to preoperative condition.
- Head injury is the most common cause of death and acquired disability in childhood.
- Falls, pedestrian-struck bicycle accidents are most common causes:
- Most severe head injuries in children are from MVA.
- Always consider possibility of nonaccidental trauma.
- <50% have altered level of consciousness (LOC):
- If EDH in differential diagnosis (DD), CT should be obtained.
- Bleeding is more likely to be venous.
- Good outcome in 95% of children <5 yr
Diagnosis
Signs and Symptoms
History
- Altered or deteriorating LOC
- LOC: 85% will have at some point in course:
- Only 11-30% will have a lucid interval.
- Nausea and vomiting: 40%
- Many times the only clinical sign is drop in hematocrit (Hct) of 40% in infants.
- Bulging fontanel with vomiting, seizures, or lethargy also suggests EDH in infants.
- <50% of children have LOC at time of injury.
- Posterior fossa lesions are seen more commonly in children.
Physical Exam
- Pupillary dilation: 20-40%:
- Usually on same side as lesion (90%)
- Hemiparesis >1/3:
- Usually on opposite side from lesion (80%)
Essential Workup
Head imaging, as below
Diagnosis Tests & Interpretation
Lab
- ABG, CBC, chemistry, PT/PTT
- Blood ETOH and drug screen as appropriate
Imaging
- Noncontrast CT of head:
- Admission perfusion CT may help predict prognosis.
- Lenticular, biconvex hematoma with smooth borders may be seen.
- Mixed density lesion may indicate active bleeding.
- Most commonly seen in temporal parietal region
- Plain films may show skull fractures:
- CT with bone windows is more often used.
- Spine series
- Further workup of trauma as indicated
US may be used for diagnosis in infants with open fontanels.
Differential Diagnosis
- History of recent head trauma lends itself to the diagnosis:
- Trauma may be minor in infants and toddlers.
- Consider other diagnosis:
- SDH
- Cerebral concussion/contusion
- Intracerebral bleed
- Diffuse axonal injury
- Subdural hygroma
- Shaken baby syndrome
- Toxic, metabolic, or infectious causes
Treatment
Pre-Hospital
- Head-injured patients have 25% improved mortality when triaged to regional trauma centers.
- Spinal immobilization is essential.
- Ensure adequate oxygenation throughout transport:
- Intubation and airway protection may be necessary.
Initial Stabilization/Therapy
- Prevent hypoxia and hypotension:
- Rapid-sequence intubation for signs of deterioration or increased intracranial pressure (ICP)
- Controlled ventilation to PCO2 of 35-40 mm Hg
- Avoid hyperventilation unless signs of brain herniation are present.
- Avoid induction agents, which may increase ICP (e.g., ketamine).
- Elevate head of bed 20 °-30 ° after adequate fluid resuscitation.
- Perform rapid neurologic assessment:
- Glasgow coma scale (GCS) score:
- 14-15; minor head injury
- 9-13; moderate head injury
- <8; severe:
- Reflexes; pupils, corneal, gag, brainstem reflexes
- Secondary survey will reveal coexisting injury in >50%.
Ed Treatment/Procedures
- Early surgical intervention (<4 hr) in comatose patients with EDH improves meaningful survival:
- Burr hole is placed at fracture site or side with ipsilateral pupillary dilation.
- Rapid craniectomy is occasionally performed if bleeding is not controlled at site of burr hole.
- Nonsurgical intervention in asymptomatic patients is associated with high rate of deterioration; >30% require surgical intervention.
- Maintain euvolemia with isotonic fluids.
- Continuous end tidal CO2 monitoring:
- Arterial line placement for close monitoring of MAP, PO2, PCO2
- Foley catheter to monitor input/output (I/O) status
- Control ICP:
- Prevent pain, posturing, and increased respiratory effort:
- Sedation with benzodiazepines
- Neuromuscular blockade with vecuronium or rocuronium in intubated patients
- Etomidate is a good induction agent.
- Barbiturate coma should be initiated for refractory increased ICP in neurosurgical ICU.
- Mannitol may be used once euvolemic:
- Shown to increase MAP greater than coronary perfusion pressure (CPP) and cerebral blood flow (CBF), as well as decrease ICP
- Keep osmolality between 295 and 310.
- Use furosemide (Lasix) as adjunct only if no risk of hypovolemia.
- Treat HTN:
- Treat hyperglycemia if present:
- Associated with increased lactic acidosis and mortality in patients with TBI
- Treat and prevent seizures:
- Not considered helpful:
- Steroids
- Antibiotic prophylaxis
- Hyperventilation in the absence of herniation
- Fluid restriction
- Calcium channel blockers
- Factors associated with poor outcome:
- Age >40 yr
- Increased admission base deficit
- Large hematoma with rapid expansion
- Increased midline shift
- Lower admission GCS or unconsciousness at presentation
- Postoperative ICP >3
- Prolonged anisocoria
- Associated brain injuries or concomitant trauma injuries
Hemodynamically significant blood loss can result from scalp lacerations and subgaleal hematomas: Direct pressure and control of bleeding is indicated.
Medication
- Diazepam: 5-10 mg (peds: 0.1-0.2 mg/kg) IV
- Dilantin: Adult/peds: Load 18 mg/kg at 25-50 mg/min
- Etomidate: 0.3 mg/kg IV
- Fentanyl: 2-4 Ug/kg IV
- Furosemide (Lasix): Adults/peds: 0.5 mg/kg IV
- Hydralazine: 10 mg/h IV (peds: 0.1-0.5 mg/kg IV) q3-4h PRN
- Labetalol: 15-30 mg/h IV (peds: 0.4-1 mg/kg/h IV continuous infusion; max. 3 mg/kg/h)
- Levetiracetam: 1,500 mg IV/PO q12h
- Lidocaine: As preinduction agent, 1.5 mg/kg IV
- Mannitol: Adults/peds: 0.25-1 g/kg IV q4h
- Midazolam: 1-2 mg (peds: 0.15 mg/kg IV — 1) IV q10min PRN
- Pentobarbital: 1-5 mg IV q6h
- Prothrombin complex concentrate 50 U/kg IV
- Rocuronium: 1 mg/kg IV
- Thiopental: As induction agent, 20 mg/kg IV
- Hypertonic saline has been shown to be beneficial in some pediatric studies (1.7-3%).
- NaCl 3%: 2-6 mL/kg IV. Infusion 0.1-1 mL/kg/h
Follow-Up
Disposition
Admission Criteria
- All patients with CT abnormality or altered LOC should be admitted to ICU setting with frequent neurologic assessment.
- Patients should have repeated CT exam in 12-24 hr or if clinical deterioration occurs.
- Patients at increased risk of deterioration include those with rapid bleeds, associated skull fracture, or lower GCS or neurologic deficits.
Discharge Criteria
Admission is necessary for all patients with EDH.
Additional Reading
- Blythe BJ, Bazarian JJ. Traumatic alterations in consciousness. Traumatic brain injury. Emerg Med Clin North Am. 2010;28(3):571-597.
- Chesnut RM. Care of central nervous system injuries. Surg Clin North Am. 2007;87(1):119-156, vii.
- Chittiboina P, Cuellar-Saenz H, Notarianni C, et al. Head and spinal cord injury: Diagnosis and management. Neurol Clin. 2012;30(1):241-276.
- Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury. Anesthesiol Clin. 2009:27(2):213-240.
- Kubal WS. Updated imaging of traumatic brain injury. Radiol Clin North Am. 2012;50(1):15-41.
- Marion DM. Epidural hematoma. In: Bradley WG, ed. Neurology in Clinical Practice. 5th ed. Elsevier; 2008:1083-1114.
Codes
ICD9
- 852.40 Extradural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness
- 852.41 Extradural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness
- 852.46 Extradural hemorrhage following injury without mention of open intracranial wound, with loss of consciousness of unspecified duration
- 852.42 Extradural hemorrhage following injury without mention of open intracranial wound, with brief [less than 1 hour] loss of consciousness
- 852.43 Extradural hemorrhage following injury without mention of open intracranial wound, with moderate [1-24 hours] loss of consciousness
- 852.44 Extradural hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness and return to pre-existing conscious level
- 852.45 Extradural hemorrhage following injury without mention of open intracranial wound, with prolonged [more than 24 hours] loss of consciousness without return to pre-existing conscious level
- 852.49 Extradural hemorrhage following injury without mention of open intracranial wound, with concussion, unspecified
- 852.4 Extradural hemorrhage following injury without mention of open intracranial wound
ICD10
- S06.4X0A Epidural hemorrhage w/o loss of consciousness, init encntr
- S06.4X7A Epidur hemor w LOC w death d/t brain injury bf consc, init
- S06.4X9A Epidural hemorrhage w LOC of unsp duration, init
- S06.4X1A Epidural hemorrhage w LOC of 30 minutes or less, init
- S06.4X2A Epidural hemorrhage w LOC of 31-59 min, init
- S06.4X3A Epidural hemorrhage w LOC of 1-5 hrs 59 min, init
- S06.4X4A Epidural hemorrhage w LOC of 6 hours to 24 hours, init
- S06.4X5A Epidural hemorrhage w LOC >24 hr w ret consc lev, init
- S06.4X6A Epidural hemorrhage w LOC >24 hr w/o ret consc w surv, init
- S06.4X8A Epidur hemor w LOC w death due to oth causes bf consc, init
SNOMED
- 428268007 epidural hematoma (disorder)
- 262949005 Traumatic extradural hematoma
- 429743002 Occipital extradural hematoma (disorder)