SUBDURAL HEMATOMA

Chelsea Deluca and Rachel Valchine

INTRODUCTION
Acute subdural hematomas (SDH) occur in approximately 5-25% of patients with severe head injuries.

SDHs are the most common type of intracranial mass lesion

PATHOPHYSIOLOGY
Subdural hematomas result when there is bleeding between the dura mater and the brain itself. Acute subdural hematomas develop rapidly, often within hours of injury. They are normally located at the top of the skull and can present bilaterally within 1520% of persons.

PATHOPHYSIOLOGY
The mechanism that produces an acute subdural hematoma is a high-speed impact to the skull. The impact can cause tearing of blood vessels that connect the cortical surface of the brain to a bridging vein. These subdural hematomas act like expanding masses, increasing intracranial pressure that can compress the bleeding veins and cause herniation.

PATHOPHYSIOLOGY
Symptoms are related to increasing intracranial pressure (ICP) and include:
Headache Drowsiness Restlessness Agitation Slowed cognition Confusion

Symptoms worsen over time and result in loss of consciousness, changes in respiratory pattern, and dilation of pupils

PATHOPHYSIOLOGY
Diagnosed with a CT scan Treatment involves decreasing ICP
Surgery for emergent decompression is advocated in only a few situation such as when the hematoma is associated with a midline shift greater than or equal to 5 mm, exceed 1 cm in thickness, or the patient is comatose with fixed/dilated pupils and an ICP that exceeds 20 mmHg.

TREATMENT
Emergency surgery
Craniotomy: in the elderly the bone flap may be left out permanently Drilling a small hole in the skull to drain CSF

Diuretics: especially Mannitol which crosses the blood-brain barrier Corticosteroids Anticonvulsion medications to prevent seizures

PATIENT CASE SCENARIO

18 yo male football player who became confused on the field. Falling to his knees, he began to vomit. His immediate complaints included severe head pain, nausea, and vertigo. The specific head injury or head contact that precipitated this event could not be identified. However, the athlete recalled being hit on 2 separate occasions during the game. No loss of consciousness was noted but he was taken by paramedics to the ED due to his unreported episodes of head trauma and symptoms associated with concussion.

PATIENT CASE SCENARIO CONT.

While he was being prepared for transfer, the patient's level of consciousness decreased, and he became less responsive. The neck was stabilized with a cervical collar to prevent further injury, although there was no cervical spine tenderness, and the patient appeared to have a mild seizure, becoming temporarily unresponsive to stimuli. In the ambulance during transport, the patient had a witnessed seizure and was incontinent of urine. Attempts to intubate him were unsuccessful due to his resistance.

PATIENT CASE SCENARIO

Assessment

On arrival at the emergency department, the athlete was oriented to time, person, and place. He complained of severe headache, nausea, and retching. He denied any neck or back pain or paresthesias. The neurologic examination revealed a Glasgow coma scale score of 15. Pupils were equal, round, and reactive to light. No nystagmus or periorbital or retroauricular ecchymosis existed, and extraocular function was intact. Reflexes and sensation were normal. Cervical, thoracic, and lumbosacral x-ray films were normal. An immediate computed tomographic (CT) scan suggested a left frontal-temporal acute subdural hematoma that measured 1.2 cm, with an equivalent left-to-right shift, although the images were not particularly remarkable.

CT scan suggesting left-temporal acute subdural hematoma measuring 1.2 cm with an equivalent left-to-right shift.

CURRENT TREATMENT
Mannitol, 80 g, given to reduce intracranial pressure upon admittance to the ED Phenytoin for prophylaxis of seizures

Admitted to neurological ICU for monitoring and additional CT scan to make sure the condition did not worsen throughout the night
The athletes condition did not worsen throughout the night and a CT scan in the morning showed that there was much less blood in the morning

He was released to the care of his parents

He was instructed not to participate in football for the remainder of the season and not to drive for 6 months

PROGNOSIS
This patients prognosis was very good because his hematoma resolved on its own In general, prognosis varies depending on type and location of the head injury, the size of the blood collection and how quickly treatment is obtained

NURSING DIAGNOSIS
Acute confusion r/t trauma aeb fluctuations in level of consciousness Acute pain r/t trauma aeb patient statement of pain level 9/10 Risk for ineffective airway clearance r/t changes in level of consciousness

NCLEX QUESTION
A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

A. To reduce intraocular pressure B. To prevent acute tubular necrosis C. To promote osmotic diuresis to decrease ICP D. To draw water into the vascular system to increase blood pressure

NCLEX QUESTION
Which of the following values is considered normal for ICP? 1. 0 to 15 mmHg 2. 25 mmHg 3. 35 to 45 mmHg 4. 120/80 mmHg

REFERENCES
Beatty, R. (1999). Subdural haematomas in the elderly. British Journal of Neurosurgery, 60-64. Heller, J. (2012, July 4). Subdural hematoma. Retrieved from MedlinePlus: www.nlm.nih.gov/medlineplus/ency/article/000713.htm Huether, S. E., & McCance, K. L. (2012). Understanding pathophysiology. St. Louis: Elsevier. Logan, S. (2001). Acute Subdural Hematoma in a High School Football Player After 2 Unreported Episodes of Head Trauma: A Case Report. Journal of Athletic Training, 433-436.

Neuro-ICP, LOC, meningitis. (n.d.). Retrieved from Student Nursing Study Blog: amy47.com/nclex-style-practice-questions/neuro-icp-loc-meningitis/
Scaletta, T. (2013, March 8). Acute Subdural Hematoma. Retrieved from Medscape: emedicine.medscape.com/article/828005-overview#a1