What is the management of an epidural hematoma in the emergency room?

Emergency Department Management of Epidural Hematoma

Epidural hematoma requires immediate neurosurgical consultation and urgent CT imaging, with surgical evacuation indicated for symptomatic patients or those with significant mass effect, while carefully selected asymptomatic patients with small hematomas may be managed conservatively with serial imaging and close neurological monitoring. 1

Immediate Assessment and Stabilization

Airway and Vital Signs

• Secure the airway with endotracheal intubation for patients with GCS ≤8, signs of herniation, or inability to protect airway 2
• Provide ventilatory and cardiovascular support as the primary objective 1
• Avoid hypotension (systolic BP <110 mmHg) and maintain adequate cerebral perfusion 1
• Monitor end-tidal CO₂ and avoid hypocapnia, which causes cerebral vasoconstriction and ischemia 2

Neurological Examination

• Document GCS score immediately, as 20% of patients deteriorate by ≥2 points between EMS assessment and ED arrival 1
• Perform pupillary examination to identify herniation risk—abnormal pupils indicate impending herniation 3
• Assess for focal neurological deficits, level of consciousness, and signs of increased intracranial pressure 1, 2
• Recognize that patients with prehospital neurologic decline have GCS decreases averaging 6 points with >75% mortality 1

Diagnostic Imaging

CT Scan Protocol

• Obtain non-contrast head CT immediately—it is the gold standard for identifying acute epidural hematoma 1
• Measure maximal hematoma thickness and degree of midline shift 3, 2
• Identify skull fractures, particularly those crossing meningeal vessels or major sinuses 4
• CT angiography may identify active contrast extravasation ("spot sign"), predicting hematoma expansion 1

Timing Considerations

• Patients imaged within 6 hours of trauma have 43% risk of subsequent deterioration requiring surgery 4
• Those diagnosed >6 hours after trauma have only 13% risk of deterioration 4

Surgical Decision-Making

Immediate Surgical Indications

• Symptomatic patients with neurological deterioration, decreased consciousness, or signs of herniation require emergency craniotomy 3, 2
• Hematoma thickness >5mm with midline shift >5mm mandates surgical evacuation 2
• Refractory intracranial hypertension despite medical management 2
• Progressive neurological decline on serial examinations 3

High-Risk Features Requiring Surgery

• Skull fracture crossing a meningeal artery, vein, or major sinus (55% deterioration rate) 4
• Presence of both risk factors (fracture over vessel AND diagnosis <6 hours) carries 71% surgical risk 4
• Active bleeding demonstrated on CT angiography 1

Conservative Management Protocol

Patient Selection Criteria

• Asymptomatic or minimally symptomatic patients with small hematomas and no mass effect 3, 4, 5
• GCS 13-15 with stable neurological examination 5
• No skull fracture overlying major vascular structures 4
• Diagnosis made >6 hours after trauma 4

Monitoring Requirements

• Serial neurological assessments every 1-2 hours initially, documenting GCS, pupils, and focal deficits 3, 2
• Repeat CT scan at 6-12 hours and again at 24 hours to monitor for expansion 4
• Maintain euvolemia and avoid hypovolemia to optimize cerebral perfusion 2
• Success rate of conservative management is 87% in appropriately selected patients 5

Medical Management of Increased ICP

Hyperosmolar Therapy

• Administer mannitol for marked improvement in consciousness when signs of increased ICP develop 1
• Consider hypertonic saline (23.4% sodium chloride 100ml IV) for acute deterioration with posturing or pupillary changes 1
• Initiate with 75ml of 10% sodium chloride IV if hemorrhage expansion occurs 1

Anticoagulation Reversal

• Rapidly reverse anticoagulation with prothrombin complex concentrate plus vitamin K for patients on warfarin 3
• Discontinue antiplatelet agents immediately 2
• Verify all anticoagulant and antiplatelet medications as these increase expansion risk 2

Neurosurgical Consultation and Transfer

Immediate Actions

• Contact neurosurgery immediately upon diagnosis—every ED must have a plan for rapid transfer to a tertiary center if neurosurgical capability is unavailable 1
• Provide advance notice to allow critical pathways activation and consulting services alert 1
• For pediatric patients with epidural hematoma, this is a time-critical transfer requiring local team transport rather than waiting for specialized transport 1

Transfer Preparation

• Stabilize patient before transfer with secured airway if indicated 1
• Maintain systolic BP <160 mmHg but avoid hypotension <110 mmHg 1
• Ensure comprehensive handover with medical notes and transfer records 1

Temporizing Measures for Delayed Neurosurgical Access

Emergency Bedside Intervention

• If neurosurgical consultation is significantly delayed and patient has active bleeding with herniation, bedside craniostomy with intraosseous drill can temporize large epidural hemorrhage 6
• Serial aspirations should be performed when hemorrhage is ongoing until definitive evacuation 6
• This technique allows immediate reduction of intracranial pressure per the Monro-Kellie Doctrine 6

Critical Pitfalls to Avoid

• Never delay surgical intervention when neurological deterioration occurs—this directly worsens outcomes 3, 2
• Do not assume clinical stability based on initial presentation—15% deteriorate within the first hour in the ED 1
• Avoid hypervolemia, which does not improve outcomes and causes complications 3
• Do not discharge patients with risk factors (fracture over vessel, diagnosis <6 hours) without serial imaging 4
• Failure of initial conservative management does not adversely affect outcome if recognized promptly 5