From the Guidelines
The primary treatment for a 48-year-old male presenting to the ED with a traumatic subdural hematoma is immediate stabilization and preparation for possible neurosurgical intervention, with a focus on maintaining systolic blood pressure > 100 mmHg, as recommended by the WSES consensus conference guidelines 1. Key steps include:
- Airway management: Intubate if GCS < 8 or airway compromise.
- Blood pressure control: Maintain systolic BP > 100 mmHg to ensure adequate cerebral perfusion, as recommended by the WSES consensus conference guidelines 1.
- Reverse anticoagulation if applicable: Administer vitamin K, fresh frozen plasma, or prothrombin complex concentrate as needed.
- Seizure prophylaxis: Administer levetiracetam 1000 mg IV.
- Elevate head of bed to 30 degrees to reduce intracranial pressure.
- Obtain urgent neurosurgical consultation for possible craniotomy or burr hole drainage.
- Perform serial neurological exams to monitor for deterioration.
- Obtain urgent CT scan if not already done. This approach aims to prevent secondary brain injury and prepare for definitive treatment. The elevated head position and blood pressure control help manage intracranial pressure, while seizure prophylaxis prevents complications that could worsen the hematoma. Rapid neurosurgical evaluation is crucial as many subdural hematomas require surgical evacuation to prevent further brain damage, as suggested by the management of severe traumatic brain injury guidelines 1. Additionally, maintaining a hemoglobin level > 7 g/dl, as recommended by the WSES consensus conference guidelines 1, and a platelet count > 50,000/mm3, as recommended by the WSES consensus conference guidelines 1, are also important in the management of traumatic subdural hematoma.
From the Research
Initial Assessment and Treatment
The treatment for a �erson presenting with a traumatic subdural hematoma in the Emergency Department involves the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach 2. This approach is widely accepted by experts in emergency medicine and is applicable in all clinical emergencies for immediate assessment and treatment.
Airway Management
Airway assessment and management skills are vital in an emergency department (ED) as they are the most sensitive indicator of patient deterioration 3. Maintaining a patient's airway and facilitating breathing is the main priority in any emergency situation. The key to safe management of an airway is thorough assessment, primarily to ensure the airway is patent.
- Assessment of the airway to determine whether it is patent or not
- Use of a bag-valve-mask to assist ventilation if necessary
- Endotracheal intubation for prolonged periods of ventilation 4
- Use of mechanical ventilators for longer term ventilatory support
Emergency Resuscitation Techniques
In emergency situations, the ABC approach represents the order of medical treatment for critically ill patients, providing supportive care (resuscitation) after ensuring the flow of oxygen supply necessary to sustain life 5. The most important goal in emergency resuscitation is to ensure a secure airway, without which, resuscitation is hopeless.
- Rapid stabilization of the airway, breathing, and circulation (ABC) to maintain cerebral perfusion
- High-quality cardiopulmonary resuscitation to reduce the duration of cerebral anoxia
- Algorithm for high-quality cardiopulmonary resuscitation as described in the literature 5
Airway Management in the Hospital Environment
In the hospital environment, patients can deteriorate rapidly and for many different reasons, making airway management crucial 6. All health professionals need to be able to undertake airway management safely, with the key being a thorough assessment to ensure the airway is patent.
- Thorough assessment to determine whether the airway is patent or not
- Ability to undertake airway management safely
- Importance of airway management in both acute and chronic situations, as well as associated nursing care 6