What are the necessary steps for an inpatient subdural hematoma workup?

From the Guidelines

For inpatient subdural hematoma workup, immediate neuroimaging with a non-contrast head CT is essential, followed by neurosurgical consultation to determine if surgical intervention is needed, as recommended by the most recent guidelines 1. The necessary steps for an inpatient subdural hematoma workup include:

• Immediate neuroimaging with a non-contrast head CT to assess the severity of the hematoma and potential mass effect
• Neurosurgical consultation to determine if surgical intervention is needed, as indicated by the presence of significant mass effect, midline shift, or herniation
• Continuous neurological monitoring with frequent assessments of Glasgow Coma Scale, pupillary responses, and vital signs to quickly identify any changes in the patient's condition
• Laboratory tests, including complete blood count, coagulation profile (PT/INR, PTT), and electrolytes, to identify any underlying coagulopathy or electrolyte imbalance that may be contributing to the hematoma
• Reversal of anticoagulants or antiplatelets, if applicable, according to specific protocols, such as vitamin K and prothrombin complex concentrate for warfarin, or platelet transfusion for antiplatelet agents, as recommended by guidelines 1
• Consideration of seizure prophylaxis with levetiracetam 500-1000 mg twice daily, especially in patients with acute subdural hematomas or those who have experienced seizures
• Pain management and elevation of the head of bed to 30 degrees to help reduce intracranial pressure
• Serial imaging, typically performed at 24 hours and then as clinically indicated, to monitor hematoma evolution and assess for any signs of worsening or improvement. These steps are crucial in managing subdural hematomas, as they can rapidly deteriorate and cause increased intracranial pressure, potentially leading to fatal brain herniation if not promptly identified and managed, as highlighted in the guidelines 1.

From the Research

Necessary Steps for Inpatient Subdural Hematoma Workup

• The workup for an inpatient subdural hematoma typically involves a combination of clinical evaluation, imaging studies, and monitoring of the patient's condition 2, 3, 4.
• Initial evaluation should include a thorough medical history, physical examination, and assessment of the patient's neurological status using the Glasgow Coma Scale (GCS) score 3, 4.
• Imaging studies, such as computed tomography (CT) scans, are crucial in diagnosing and evaluating the size and location of the subdural hematoma 2, 3, 4, 5.
• Patients with small isolated traumatic subdural hemorrhage (<10 cm(3)) may not require intensive care unit (ICU) monitoring, but those with larger hematomas or additional intracranial hemorrhages may benefit from ICU observation 2.
• The decision to operate on a patient with a subdural hematoma depends on various factors, including the size and location of the hematoma, the patient's GCS score, and the presence of other intracranial injuries 3, 4.
• Patients with acute subdural hematomas who are in coma (GCS score less than 9) should undergo intracranial pressure (ICP) monitoring, and those with indications for surgery should undergo surgical evacuation as soon as possible 4.
• In patients with chronic subdural hematoma who are on anticoagulation therapy, immediate correction of hypocoagulability and careful surgical management are essential to prevent complications 6.
• Repeat CT scans may be indicated in patients with persistent symptoms after minor head trauma, even if the initial CT scan is normal 5.

Key Considerations

• The GCS score is an important tool in evaluating the severity of head injury and predicting the need for surgical intervention 3, 4.
• CT scans are sensitive in detecting subdural hematomas, but repeat scans may be necessary to monitor the size and location of the hematoma 2, 5.
• Patients with subdural hematomas require close monitoring and prompt intervention if their condition deteriorates 2, 3, 4.
• The management of subdural hematomas in patients on anticoagulation therapy requires careful consideration of the risks and benefits of surgical intervention 6.