What is the recommended anesthesia management for Epidural Hematoma (EDH)?

Anesthesia Management in Epidural Hematoma (EDH)

General anesthesia with rapid sequence induction, endotracheal intubation, and careful blood pressure management is the recommended anesthetic approach for patients with epidural hematoma requiring surgical evacuation.

Pre-operative Assessment and Preparation

• Rapidly assess neurological status using Glasgow Coma Scale (GCS)
• Pay special attention to:
  • Signs of increased intracranial pressure (ICP)
  • Pupillary abnormalities (anisocoria strongly indicates need for immediate surgery) 1
  • Vital signs (particularly Cushing's triad: hypertension, bradycardia, irregular respiration)
  • Coagulation status, especially if patient is on anticoagulants 2

Anesthetic Management

Induction and Airway Management

• Rapid sequence induction with:
  • Propofol (reduced dose in hemodynamically unstable patients) or etomidate
  • Rocuronium or succinylcholine for muscle relaxation
  • Avoid prolonged periods of hypotension during induction
• Secure airway with endotracheal intubation
• Avoid excessive coughing or straining during intubation which can increase ICP

Maintenance

• Volatile anesthetics at low concentrations (0.5-0.7 MAC) combined with opioid infusion 3
• Total intravenous anesthesia (TIVA) with propofol and remifentanil/fentanyl is an excellent alternative
• Maintain normocapnia (PaCO2 35-40 mmHg) to prevent cerebral vasodilation
• Avoid nitrous oxide due to its cerebral vasodilatory effects and potential to increase ICP

Hemodynamic Management

• Maintain systolic blood pressure within 90-160 mmHg to ensure adequate cerebral perfusion pressure
• Avoid hypotension which can worsen secondary brain injury
• Use direct arterial pressure monitoring
• Consider central venous access in hemodynamically unstable patients

ICP Management

• Position head elevated 15-30 degrees to facilitate venous drainage
• Maintain normothermia
• Consider mannitol or hypertonic saline if signs of increased ICP persist
• Avoid excessive fluid administration

Special Considerations

Pediatric Patients

• Children with EDH may present with irritability rather than typical symptoms 4
• Adjust drug dosages according to weight
• More vigilant hemodynamic control due to lower blood volume

Anticoagulated Patients

• Higher mortality risk in patients on anticoagulant therapy 2
• Urgent reversal of anticoagulation before surgery
• Consider blood product availability (FFP, platelets, cryoprecipitate)

Elderly Patients

• Higher mortality risk 2
• More cautious induction with reduced doses
• More aggressive hemodynamic monitoring

Post-operative Care

• Plan for early neurological assessment
• Consider delayed extubation in patients with preoperative GCS <9
• Continue ICP monitoring if indicated
• Maintain normocapnia, normothermia, and appropriate blood pressure control

Pitfalls to Avoid

• Delaying surgery in patients with GCS <9 and anisocoria (immediate evacuation recommended) 1
• Excessive hyperventilation which can reduce cerebral blood flow
• Inadequate depth of anesthesia during intubation leading to ICP spikes
• Hypotension during induction or maintenance phases
• Hypertension during emergence causing rebleeding
• Inadequate reversal of neuromuscular blockade interfering with neurological assessment

While neuraxial techniques are commonly used for various procedures 3, they are contraindicated in EDH cases due to the risk of increased ICP and potential herniation. The focus must remain on rapid surgical intervention, as patients taken to surgery within 12 hours have better neurological outcomes than those with delayed surgery 5.