Diferencia entre revisiones de «Epidural hemorrhage»

(Major expansion: EM-focused content, clinical features, management with dosing, peer-reviewed references)
(Strip excess bold)
 
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==Background==
==Background==
*Bleeding between the skull and dura mater, typically from rupture of the '''middle meningeal artery'''
*Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
*Usually associated with temporal bone fracture<ref name="bullock">Bullock MR, et al. Surgical management of acute epidural hematomas. ''Neurosurgery''. 2006;58(3 Suppl):S7-15. PMID 16710967.</ref>
*Usually associated with temporal bone fracture<ref name="bullock">Bullock MR, et al. Surgical management of acute epidural hematomas. ''Neurosurgery''. 2006;58(3 Suppl):S7-15. PMID 16710967.</ref>
*Accounts for 1-4% of traumatic [[Head trauma (main)|head injuries]]
*Accounts for 1-4% of traumatic [[Head trauma (main)|head injuries]]
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==Clinical Features==
==Clinical Features==
*Classic presentation ('''lucid interval''' in ~30% of cases):
*Classic presentation (lucid interval in ~30% of cases):
**Initial loss of consciousness (LOC) after head trauma
**Initial loss of consciousness (LOC) after head trauma
**Transient period of lucidity
**Transient period of lucidity
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==Evaluation==
==Evaluation==
*'''Non-contrast CT head''' — test of choice<ref name="dent">Dent DL, et al. Prognostic factors after acute subdural hematoma. ''J Trauma''. 1995;39(1):36-43. PMID 7636907.</ref>
*Non-contrast CT head — test of choice<ref name="dent">Dent DL, et al. Prognostic factors after acute subdural hematoma. ''J Trauma''. 1995;39(1):36-43. PMID 7636907.</ref>
**Biconvex (lens-shaped) hyperdense collection
**Biconvex (lens-shaped) hyperdense collection
**Does NOT cross suture lines (confined by dural attachments)
**Does NOT cross suture lines (confined by dural attachments)
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==Management==
==Management==
*'''ABCs''' — secure airway early if declining GCS
*ABCs — secure airway early if declining GCS
*'''Emergent neurosurgical consultation'''
*Emergent neurosurgical consultation
*Indications for surgical evacuation (craniotomy):
*Indications for surgical evacuation (craniotomy):
**EDH >30 mL regardless of GCS
**EDH >30 mL regardless of GCS
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*ICP management while awaiting surgery:
*ICP management while awaiting surgery:
**Elevate head of bed 30 degrees
**Elevate head of bed 30 degrees
**'''[[Mannitol]]''' 1-1.5 g/kg IV bolus or '''[[Hypertonic saline]]''' 23.4% 30 mL IV
**[[Mannitol]] 1-1.5 g/kg IV bolus or [[Hypertonic saline]] 23.4% 30 mL IV
**Controlled [[Intubation (main)|intubation]] if GCS <=8; target PaCO2 35 mmHg
**Controlled [[Intubation (main)|intubation]] if GCS <=8; target PaCO2 35 mmHg
**Avoid hypotension (maintain MAP >80)
**Avoid hypotension (maintain MAP >80)
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==Disposition==
==Disposition==
*All EDH require '''admission''' with neurosurgical involvement
*All EDH require admission with neurosurgical involvement
*ICU admission for any operative EDH or declining neurologic exam
*ICU admission for any operative EDH or declining neurologic exam
*Repeat CT in 6-8 hours for non-operative cases
*Repeat CT in 6-8 hours for non-operative cases

Revisión actual - 09:26 22 mar 2026

Background

  • Bleeding between the skull and dura mater, typically from rupture of the middle meningeal artery
  • Usually associated with temporal bone fracture[1]
  • Accounts for 1-4% of traumatic head injuries
  • Bimodal age distribution: most common in adolescents and young adults
  • Rare in elderly (dura more adherent to skull) and infants <2 years
  • Carries ~5-10% mortality with prompt treatment; higher if uncal herniation occurs

Clinical Features

  • Classic presentation (lucid interval in ~30% of cases):
    • Initial loss of consciousness (LOC) after head trauma
    • Transient period of lucidity
    • Rapid deterioration with decreasing GCS, ipsilateral pupil dilation
  • Headache, nausea, vomiting
  • Signs of increased ICP: Cushing response (hypertension, bradycardia, irregular respirations)
  • Ipsilateral fixed, dilated pupil (uncal herniation)
  • Contralateral hemiparesis
  • May present without lucid interval, especially with severe injury

Differential Diagnosis

Evaluation

  • Non-contrast CT head — test of choice[2]
    • Biconvex (lens-shaped) hyperdense collection
    • Does NOT cross suture lines (confined by dural attachments)
    • May see associated skull fracture, midline shift, mass effect
  • Labs: CBC, coagulation studies, type and screen
  • Evaluate for cervical spine injury and other traumatic injuries

Management

  • ABCs — secure airway early if declining GCS
  • Emergent neurosurgical consultation
  • Indications for surgical evacuation (craniotomy):
    • EDH >30 mL regardless of GCS
    • Clot thickness >15 mm or midline shift >5 mm
    • GCS declining or GCS <9 with pupil abnormalities
  • ICP management while awaiting surgery:
    • Elevate head of bed 30 degrees
    • Mannitol 1-1.5 g/kg IV bolus or Hypertonic saline 23.4% 30 mL IV
    • Controlled intubation if GCS <=8; target PaCO2 35 mmHg
    • Avoid hypotension (maintain MAP >80)
  • Small EDH (<30 mL, <15 mm thick, <5 mm shift, GCS >8): may be managed non-operatively with serial CT and close neuro monitoring

Disposition

  • All EDH require admission with neurosurgical involvement
  • ICU admission for any operative EDH or declining neurologic exam
  • Repeat CT in 6-8 hours for non-operative cases

See Also

References

  1. ↑ Bullock MR, et al. Surgical management of acute epidural hematomas. Neurosurgery. 2006;58(3 Suppl):S7-15. PMID 16710967.
  2. ↑ Dent DL, et al. Prognostic factors after acute subdural hematoma. J Trauma. 1995;39(1):36-43. PMID 7636907.
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