What are the guidelines for managing a young adult or adult patient with an epidural hematoma (EDH) and a history of head trauma, possible bleeding disorders, or anticoagulant use?

Guidelines for Epidural Hematoma (EDH) Management

Immediate Surgical Indications

An epidural hematoma greater than 30 cm³ requires surgical evacuation regardless of the patient's Glasgow Coma Scale (GCS) score. 1

Absolute Surgical Criteria

• EDH volume >30 cm³ mandates immediate craniotomy 1
• Thickness >15 mm requires surgical evacuation 1
• Midline shift >5 mm necessitates urgent surgery 1
• Comatose patients (GCS <9) with anisocoria require evacuation as soon as possible 1
• Any life-threatening brain lesion after hemorrhage control demands urgent neurosurgical consultation and intervention 2

Conservative Management Criteria

Small EDH (<30 cm³, <15 mm thickness, <5 mm midline shift) in patients with GCS >8 without focal deficits can be managed nonoperatively with serial CT scanning and close neurological observation in a neurosurgical center. 1

Risk Stratification for Conservative Management

• Patients with skull fracture overlying a meningeal artery, vein, or major sinus have 55% risk of deterioration requiring surgery 3
• Patients diagnosed within 6 hours of trauma have 43% risk of requiring delayed evacuation 3
• Patients with both risk factors have 71% chance of requiring surgical intervention 3
• Patients diagnosed >6 hours after trauma without vascular fracture have only 13% risk of deterioration and are suitable for conservative management 3

Monitoring Protocol for Conservative Management

Neurological Assessment

• GCS monitoring every 15 minutes for first 2 hours, then hourly for 12 hours 4
• Document individual GCS components (Eye, Motor, Verbal) and pupillary size/reactivity at each evaluation 4
• Immediate repeat CT for GCS decline ≥2 points 4

Repeat Imaging Schedule

• Repeat head CT at 6-8 hours after initial scan to assess for hemorrhage expansion 4
• Serial CT scanning with close neurological observation is mandatory for all conservatively managed cases 1
• Repeat CT within 24 hours for anticoagulated patients due to 3-fold increased risk of hemorrhage expansion 5, 4

Hemodynamic Management

Maintain systolic blood pressure >100 mmHg or mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery. 2

Blood Pressure Targets

• SBP >100 mmHg or MAP 80-110 mmHg to ensure adequate cerebral perfusion 2, 6
• In combined hemorrhagic shock without brain injury, target SBP 80-90 mmHg until bleeding controlled 2
• Lower values may be tolerated briefly during difficult intraoperative bleeding control 2

Additional Physiologic Parameters

• Maintain PaO₂ between 60-100 mmHg during surgery 2
• Maintain PaCO₂ between 35-40 mmHg during surgery 2
• Transfuse RBCs for hemoglobin <7 g/dL (higher threshold for elderly or cardiac disease) 2

Management of Anticoagulated Patients with EDH

Immediate Reversal Protocol

• Discontinue anticoagulant immediately upon EDH diagnosis 5
• For warfarin: administer 4-factor PCC 25-50 IU/kg plus IV vitamin K 5-10 mg to achieve INR <1.5 5
• Administer 4F-PCC without waiting for INR results if intracranial hemorrhage suspected based on clinical deterioration 5
• Always give IV vitamin K (5-10 mg) alongside PCC to prevent rebound INR increases over 12-24 hours 5

Platelet Management

• Maintain platelet count >50,000/mm³ for life-threatening hemorrhage intervention 2
• Higher platelet threshold advisable for emergency neurosurgery including ICP probe insertion 2

Intracranial Pressure Management

Patients at risk for intracranial hypertension (comatose with radiological signs of IH) require ICP monitoring regardless of need for emergency extra-cranial surgery. 2

Herniation Management

• Use osmotherapy and/or temporary hypocapnia in cases of cerebral herniation awaiting or during emergency neurosurgery 2
• Osmotherapy includes mannitol or hypertonic saline 2

Common Pitfalls to Avoid

• Never discharge patients with documented EDH based solely on normal neurological examination - delayed deterioration can occur even in stable patients 4
• Do not use fresh frozen plasma as first-line therapy when 4F-PCC available - it is slower and increases volume overload risk 5
• Avoid administering long-acting sedatives or paralytics before neurosurgical evaluation - this masks clinical deterioration 4
• Do not delay reversal waiting for INR results if clinical deterioration suggests intracranial hemorrhage 5
• Never assume minimal symptoms indicate benign course - intracranial hemorrhage can present minimally but deteriorate rapidly 6

Surgical Technique

Craniotomy provides more complete evacuation of the hematoma compared to other methods, though insufficient data exist to mandate one specific surgical approach. 1