epidural hematoma

Epidural Hematoma

Causes

Genetic considerations

Gender, ethnic/racial, and life span considerations

Global health considerations

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, 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.

Physical examination

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.

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

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

Primary nursing diagnosis

Diagnosis

Outcomes

Interventions

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 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.

Pharmacologic highlights

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.

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. 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.

Documentation guidelines

• 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.