What is the initial treatment for an epidural hematoma in the Emergency Department (ED) prior to surgical intervention?

Initial Treatment of Epidural Hematoma in the Emergency Department

For patients with epidural hematoma in the ED, immediate priorities are airway protection, blood pressure management, reversal of coagulopathy if present, and urgent neurosurgical consultation for surgical evacuation, as epidural hematomas are neurosurgical emergencies requiring rapid intervention to prevent herniation and death. 1

Immediate Resuscitation and Stabilization

Airway and Breathing Management

• Intubate patients with GCS ≤8 or those showing signs of neurological deterioration to protect the airway and prevent hypoxia, which causes secondary brain injury 1
• Avoid hyperventilation during mechanical ventilation, as it increases mortality in trauma patients and decreases cardiac output 1
• Maintain oxygen saturation >94% to prevent cerebral hypoxia 1
• Use caution with excessive positive end-expiratory pressure (PEEP) in hypovolemic patients, as it can decrease cardiac output 1

Hemodynamic Management

• Maintain systolic blood pressure >100 mmHg to ensure adequate cerebral perfusion 1
• Establish large-bore IV access immediately for fluid resuscitation if needed 1
• Avoid hypotension, which is a critical cause of secondary brain injury 1

Neurological Assessment and Monitoring

Initial Evaluation

• Perform rapid GCS assessment and pupillary examination to establish baseline neurological status 1, 2
• Document focal neurological deficits, level of consciousness, and any signs of herniation 1
• Repeat neurological assessments at least every 4 hours initially, as 15% of patients deteriorate within the first hour of ED presentation 1, 2

Imaging

• Obtain non-contrast head CT immediately as the gold standard for identifying acute hemorrhage 1
• CT angiography may identify active bleeding (contrast extravasation) indicating high risk for hematoma expansion 1
• Do not delay imaging for any reason in suspected epidural hematoma 1

Medical Management to Reduce Intracranial Pressure

Osmotic Therapy

• Administer mannitol 0.25 to 2 g/kg IV over 30-60 minutes for reduction of intracranial pressure and brain mass 3
• For small or debilitated patients, 500 mg/kg may be sufficient 3
• Evidence of reduced cerebrospinal fluid pressure should be observed within 15 minutes of starting infusion 3
• Monitor fluid and electrolyte balance, body weight, and total input/output before and after mannitol administration 3

Temperature and Seizure Control

• Prevent hyperthermia, as it increases cerebral oxygen demand and worsens secondary brain injury 1
• Treat seizures aggressively if they occur, as they increase metabolic demand 1

Reversal of Coagulopathy

Anticoagulation Reversal

• For patients on warfarin, immediately reverse with prothrombin complex concentrate (PCC) or fresh frozen plasma 1
• For novel oral anticoagulants (NOACs), specific reversal agents should be used when available, though clinical experience is limited 1

Antiplatelet Therapy

• Evidence for platelet transfusion in patients on antiplatelet drugs is insufficient, but consider in consultation with neurosurgery 1
• Do not use recombinant factor VIIa (rFVIIa) routinely outside of clinical trials 1

Urgent Neurosurgical Consultation and Transfer

Timing Considerations

• Contact neurosurgery immediately upon diagnosis, as the commonly accepted target is surgery within 4 hours of injury, though this is not strictly evidence-based 1
• Do not delay transfer to a neurosurgical center - lack of critical care beds should never be a reason for refusing admission for patients requiring emergency surgery 1
• Networks should work toward auto-acceptance criteria for brain-injured patients similar to trauma networks 1

Indications for Immediate Surgery

• Any patient with epidural hematoma who is deteriorating neurologically requires immediate surgical evacuation 1, 4
• Patients with decreased level of consciousness (GCS ≤8) 1
• Presence of mass effect, midline shift, or signs of herniation 1
• Hematoma volume considerations and location guide surgical urgency 4

Alternative Interventions in Select Cases

Endovascular Embolization

• Middle meningeal artery embolization may be considered in highly selected cases with active bleeding on CT angiography, particularly when surgical access is limited 5
• This remains an emerging technique and should not delay traditional surgical evacuation in most cases 5

Burr Hole Drainage

• In emergency situations where neurosurgical expertise or facilities are unavailable, burr hole evacuation with drainage under negative pressure may be performed as a temporizing measure 6
• This should be followed by daily CT scans and definitive craniotomy if consciousness does not improve within several hours 6

Critical Pitfalls to Avoid

• Never delay surgical consultation or transfer - epidural hematomas can expand rapidly and cause herniation within hours 1
• Do not perform lumbar puncture in patients with suspected epidural hematoma, as it can precipitate herniation 1
• Avoid hyperventilation during resuscitation, as it worsens outcomes 1
• Do not use excessive PEEP in hypovolemic patients 1
• Do not wait for neurological deterioration to occur before arranging transfer - proactive transfer to neurosurgical centers improves outcomes 1
• Recognize that chronic epidural hematomas (>72 hours) should still be operated on immediately despite the delay 4