WORKUP	Section 5 of 10
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Lab Studies:

• Complete blood count (CBC) with platelets - To monitor for infection and assess hematocrit and platelets for further hemorrhagic risk

• Prothrombin time (PT)/activated partial thromboplastin time (aPTT) - To identify bleeding diathesis

• Serum chemistries, including electrolytes, blood urea nitrogen (BUN), creatinine, and glucose - To characterize metabolic derangements that may complicate clinical course

• Toxicology screen and serum alcohol level - To identify associated causes of head trauma and establish need for surveillance with regard to withdrawal symptoms

• Type and hold an appropriate amount of blood - To prepare for necessary transfusions needed because of blood loss or anemia

Imaging Studies:

• Plain radiography of the head (skull radiography) may reveal skull fractures, though CT scanning has largely replaced the use of skull radiography because the diagnostic information is so much greater with CT. Cervical spine radiographs with anteroposterior, lateral, and odontoid views are useful to identify associated traumatic fractures. Plain radiographs of the vertebral column may identify a cavernous angioma.

• Myelography outlines the epidural space and may illustrate a space-occupying mass. CT myelography may be used when MRI is unavailable or if the patient cannot tolerate MRI.

• Noncontrast CT scanning of the head not only visualizes skull fractures but also directly images an epidural hematoma.

• Acute epidural hematoma may appear as a hyperdense lenticular-shaped mass situated between the brain and the skull, though regions of hypodensity may be seen with serum or fresh blood. On rare occasion, an acute epidural may appear completely isointense with respect to brain. Planoconvex or crescent-shaped epidural hematoma must be differentiated from subdural hemorrhage. Subacute lesions are homogenously hyperdense.

• Chronic epidural hematoma may have a heterogeneous appearance due to neovascularization and granulation, with peripheral enhancement on contrast administration.

• CT scanning may also depict air collections and displacement of brain parenchyma.

• Clinical deterioration should prompt repeat imaging with CT scanning.

• MRI also demonstrates the evolution of an epidural hematoma, though this imaging modality may not be appropriate for patients in unstable condition.

• Spinal MRI may delineate the location of an epidural hematoma and identify an associated vascular malformation.

• Spinal cord enhancement may be apparent and should be distinguished from inflammation or neoplasia.

• Diffusion-weighted imaging with the use of periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) MRI may be used for improved detection of acute spinal epidural hematoma.

• Gadolinium-enhanced magnetic resonance arteriography (MRA) may further define the extent of an arteriovenous malformation.

• Conventional angiography may be required to demonstrate definitively the presence of a vascular malformation.

Other Tests:

• Functional studies of the spinal cord, such as somatosensory evoked potentials, may be used for intraoperative monitoring or for prognostication following surgery.

Procedures:

• Emergent decompression with placement of a burr hole may be necessary when neurosurgical consultation is unavailable. For patients showing rapid deterioration with clinical signs of impending herniation, place a burr hole on the side of the dilating pupil. In the absence of a CT scan, place the burr hole 2 finger widths anterior to the tragus of the ear and 3 finger widths above the tragus of the ear.

• Lumbar puncture provides little additional information and may exacerbate neurological damage.

	TREATMENT	Section 6 of 10
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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 x-rays 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 28-32 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.

Surgical Care: Although several recent reports have described successful conservative management of epidural hematoma, surgical evacuation constitutes definitive treatment of this condition. Craniotomy or laminectomy is followed by evacuation of the hematoma, coagulation of bleeding sites, and inspection of the dura. The dura is then tented to the bone and, occasionally, epidural drains are employed for as long as 24 hours.

• Minimally invasive surgical procedures, including the use of burr holes and negative pressure drainage, may be used in selected cases.

• Novel therapeutic approaches may include the use of endovascular embolization to minimize bleeding during the acute stage.

Consultations:

• Neurosurgeon (for potential emergent evacuation of the hematoma)

• Neurologist

• Rehabilitation specialist

Diet: The hypermetabolic and catabolic phenomena associated with severe head injury necessitate caloric supplementation. Initiate enteral feedings as soon as possible.

	MISCELLANEOUS	Section 9 of 10
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Medical/Legal Pitfalls:

• Consider epidural hematoma in all patients who have experienced head injury.

• Alteration in the level of consciousness may be highly variable and unreliable as a clinical predictor.

• Obtain CT scan whenever possible.

• Skull fractures are not always present, particularly in children.

• Delayed transfer and triage may be the principal determinant of death.

• Close observation requires frequent neurologic evaluations.