What is the immediate management for a patient with a cranial fracture and potential epidural hematoma?

Immediate Management of Cranial Fracture with Potential Epidural Hematoma

For a patient with cranial fracture and potential epidural hematoma, immediately obtain non-contrast head CT to confirm the diagnosis, secure the airway if GCS ≤8, maintain systolic blood pressure >100 mmHg (or MAP >80 mmHg), and obtain urgent neurosurgical consultation for all patients with altered mental status or significant hematoma on imaging. 1, 2, 3

Initial Stabilization

Airway Management

• Do not intubate based solely on GCS score, but prepare for intubation if GCS ≤8, deteriorating consciousness, loss of protective airway reflexes, or signs of impending herniation 2, 3
• Secure the airway via tracheal intubation for patients with GCS ≤8 3

Hemodynamic Targets

• Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during all interventions and throughout the acute phase 1, 3
• Target cerebral perfusion pressure (CPP) between 60-70 mmHg after ICP monitor placement 1
• Avoid CPP >70 mmHg routinely, as CPP >90 mmHg worsens neurological outcomes due to vasogenic cerebral edema 1

Respiratory Parameters

• Maintain PaO₂ between 60-100 mmHg to ensure adequate oxygenation without hyperoxia 1, 3
• Target PaCO₂ between 35-40 mmHg (normocapnia) during all interventions 1, 3
• Reserve hypocapnia (temporary hyperventilation) only for cases of cerebral herniation while awaiting emergency neurosurgery 1, 3

Diagnostic Evaluation

Immediate Imaging

• Obtain non-contrast head CT immediately to characterize the epidural hematoma and assess for midline shift and life-threatening mass effect 1, 2
• Perform urgent neurological evaluation including pupillary examination, Glasgow Coma Scale motor score, and full neurological assessment 1, 2

Serial Monitoring Protocol

• Monitor GCS every 15 minutes for the first 2 hours, then hourly for the following 12 hours 1
• Document individual GCS components (Eye, Motor, Verbal) and pupillary size/reactivity at each evaluation 1
• A decrease of 2 or more points in GCS score warrants immediate repeat CT scanning 1
• Obtain repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion, as most expansion occurs within the first 6 hours 1

Neurosurgical Consultation Criteria

Immediate Consultation Required For:

• All patients with altered mental status (GCS <15) 2
• Development of pupillary changes or posturing indicating herniation 1
• GCS decline of ≥2 points 1
• Development of focal neurological deficits indicating mass effect 1
• Midline shift >5 mm with low GCS scores 1
• EDH thickness >5 mm with midline shift >5 mm 1

Surgical Timing

• Surgical evacuation should be performed as soon as possible after the decision is made, as delaying surgery in patients with significant midline shift and low GCS scores is associated with poorer outcomes 1
• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after control of life-threatening hemorrhage 1, 3

Conservative Management Considerations

While most epidural hematomas require surgical evacuation, conservative management may be considered only in highly selected cases with specific criteria:

Criteria for Conservative Management (If Available):

• Patient must be neurologically asymptomatic with no clinical evidence of raised intracranial pressure or focal compression 4
• Small hematoma size 4, 5
• However, 32% of initially asymptomatic patients subsequently required evacuation 1-10 days after initial trauma 4

High-Risk Features for Deterioration:

• Skull fracture transversing a meningeal artery, vein, or major sinus (55% deterioration rate) 4
• CT diagnosis within 6 hours of trauma (43% deterioration rate) 4
• Patients with both risk factors have 71% chance of requiring evacuation 4

Requirements for Conservative Management:

• Facility must have immediate capability to perform craniotomy with evacuation if neurological worsening occurs 5
• Trained staff available to carry out serial neurological examinations 5
• Close clinical observation with serial imaging 4, 5

Admission and Monitoring

Mandatory Admission

• Any documented epidural hematoma on CT requires admission, regardless of GCS score, as delayed deterioration can occur even in neurologically stable patients 1
• Admit patients to ICU or step-down unit with neurosurgical consultation 2
• Admit for close neurological observation for 24-72 hours with serial clinical assessments 1

ICP Monitoring

• All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension require ICP monitoring regardless of whether they undergo emergency neurosurgery 1
• Intraparenchymal probes are preferred over ventricular catheters due to better risk-benefit profile 1

Coagulation Management

Anticoagulation Reversal

• Reverse anticoagulation immediately if the patient is on warfarin, NOACs, or antiplatelet agents 1
• Hold aspirin immediately upon diagnosis, as elderly patients (≥65 years) on aspirin have 3-fold increased risk of hemorrhage progression 1

Transfusion Targets

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions 1
• Maintain platelet count >50,000/mm³ for systemic hemorrhage control 1
• Maintain PT/aPTT <1.5 times normal control during all interventions 1

Critical Pitfalls to Avoid

• Do not discharge patients with documented epidural hematomas based solely on normal neurological examination 1
• Do not administer long-acting sedatives or paralytics before neurosurgical evaluation, as this masks clinical deterioration 1
• Do not fail to maintain mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1
• Do not delay transfer for "medical optimization" beyond basic resuscitation in patients requiring neurosurgical intervention, as this is a time-critical emergency 1
• Do not delay intubation in patients with low GCS scores, as this is a clear indication for airway protection 3
• Avoid hypotension and hypoxia, which can worsen secondary brain injury 3

Transfer Considerations

• Urgent transfer with appropriate monitoring and medications during transport is necessary if neurosurgical capabilities are not available at the facility 2
• Provide ventilatory and cardiovascular support while transporting the patient to the closest facility prepared to care for acute neurosurgical patients 3