What are the key components of a physical exam for suspected traumatic subdural hematoma (SDH)?

Physical Examination for Traumatic Subdural Hematoma

A thorough neurological assessment focusing on level of consciousness, pupillary response, and focal neurological deficits is the cornerstone of physical examination for suspected traumatic subdural hematoma (SDH).

Initial Neurological Assessment

Level of Consciousness

• Glasgow Coma Scale (GCS) assessment is critical - scores of 3-4 or deteriorating scores strongly correlate with poor outcomes 1
• Document any change in GCS between prehospital and hospital admission (deterioration is a significant predictor of need for surgical intervention) 2
• GCS <14 is a risk factor that indicates higher risk of neurological deterioration 3

Pupillary Examination

• Check for:
  • Pupillary asymmetry (anisocoria)
  • Bilateral mydriasis (dilated pupils)
  • Abnormal pupillary light reflexes
  • Pupillary reactivity (sluggish or non-reactive pupils suggest increased intracranial pressure) 1

Motor Function Assessment

• Evaluate for:
  • Motor response (part of GCS scoring)
  • Asymmetric motor weakness
  • Lateralizing signs (hemiparesis)
  • Abnormal posturing (decorticate or decerebrate)
  • GCS motor response ≤5 is a significant indicator of severity 1

Vital Signs and Systemic Examination

• Blood pressure and heart rate (Cushing's triad: hypertension, bradycardia, irregular respirations)
• Respiratory pattern (look for Cheyne-Stokes respiration or irregular breathing)
• Temperature (hyperthermia may indicate hypothalamic involvement)
• Evidence of hemodynamic instability (a risk factor for poor outcomes) 1

Cranial Nerve Examination

• Assess extraocular movements (cranial nerves III, IV, VI)
• Check facial symmetry (cranial nerve VII)
• Evaluate gag reflex if safe to do so (cranial nerves IX, X)
• Note any dysarthria or dysphagia

Additional Neurological Signs

• Check for:
  • Ataxia (may indicate cerebellar involvement) 1
  • Sensory deficits
  • Reflexes (hyperreflexia or asymmetry)
  • Babinski sign (upgoing plantar response)
  • Signs of increased intracranial pressure (headache, vomiting, altered mental status)

Examination for Associated Injuries

• Inspect for:
  • Signs of head trauma (scalp lacerations, contusions, Battle's sign, raccoon eyes)
  • Hemotympanum or cerebrospinal fluid otorrhea/rhinorrhea
  • Cervical spine tenderness or pain (consider associated cervical spine injury) 1, 4
  • Evidence of polytrauma (thoracic, abdominal, or extremity injuries)

Risk Stratification Based on Physical Findings

• High-risk features requiring immediate neurosurgical evaluation:
  • GCS score <14
  • Deteriorating GCS score
  • Anisocoria or bilateral mydriasis
  • Focal neurological deficits
  • Age >65 years (associated with higher mortality) 5

Pitfalls to Avoid

• Failing to perform serial neurological examinations (SDH can evolve from acute to subacute with delayed deterioration) 6
• Overlooking subtle neurological changes in elderly patients
• Missing signs of associated cervical spine injuries (present in >36% of cases with significant head trauma) 1
• Administering long-lasting sedatives or paralytic agents before complete neurological assessment 2
• Relying solely on physical examination without appropriate imaging in high-risk patients

The physical examination findings should be integrated with imaging findings (particularly CT scan) to guide management decisions. CT parameters such as hematoma thickness >5mm, midline shift >5mm, and presence of multiple discrete hematomas are important risk factors that complement the physical examination 2, 3.