Epidural Hematoma (EDH)

Time is the operation - This is a neurosurgical emergency and the target is intervention within one to two hours of presentation; delay to evacuation is what drives morbidity and mortality. Lines and monitors are worth having but not worth holding the incision for — place them while the patient is being prepped and draped.

Read the pupils and the posture - A single fixed dilated pupil is uncal herniation compressing the oculomotor nerve. Bilateral fixed dilated pupils mean severe ICP, bilateral herniation, or hypoxemia. Decorticate posturing localizes the injury above the midbrain, decerebrate below it. Cushing triad — hypertension, bradycardia, irregular respirations — is a late, near-terminal sign, not an early warning.

Perfusion targets - ICP is normally under 20 mmHg, and a sustained ICP above 20 to 25 mmHg tracks with poor neurologic outcome. After severe traumatic brain injury the recommended CPP target is above 60 to 70 mmHg. Since CPP = MAP - ICP, the MAP you accept is set by the ICP you believe the patient has.

Blood pressure cuts both ways - Hypotension drops CPP straight into ischemia. But the hypertension in front of you may be the Cushing response holding perfusion up, and in a bleeding brain a higher pressure also worsens the bleed. Treat the ICP first rather than chasing the number down with vasodilators.

Airway - Trauma patient: assume a full stomach and an uncleared cervical spine, and manage it as RSI with manual in-line stabilization. C-spine imaging is part of the workup for anyone comatose after head trauma.

Basilar skull fracture rules - No nasogastric tube, no nasotracheal intubation, and no nasal positive pressure. The tube can end up intracranial, and nasal NIPPV can drive pneumocephalus.

Ventilation - Keep normocarbia. Hypercarbia dilates cerebral vessels and adds volume the vault has no room for, but routine hyperventilation is associated with worse outcomes in traumatic brain injury. Reserve it for impending herniation as a bridge to decompression, and know that cerebral vasoconstriction is already maximal below a PaCO2 of 25 mmHg and the effect washes out in 6 to 18 hours.

ICP moves you own - Head up 30 to 45 degrees, hyperosmolar therapy with mannitol, CSF drainage if a ventriculostomy is in, and deepening toward burst suppression to drop CMRO2 and with it cerebral blood volume.

Coagulation - Send INR, PT, PTT, and a platelet count, and ask directly about antiplatelet and anticoagulant drugs. Abnormal clotting is common after head injury and is what turns a stable clot into an expanding one. Have blood available; scalp and craniotomy bleeding is not trivial.

The decompression moment - When the flap comes off and the dura opens, the pressure the clot was generating disappears in seconds. Have a vasopressor drawn up and expect the blood pressure to fall.

Seizures - Seizure is a common presenting feature of intracranial hemorrhage. If an antiepileptic was loaded before the patient came to you, carry it through the case.

Emergence - The neurologic exam is the monitor once this case is over. Either build an anesthetic that lets an exam happen in the room, or decide with the neurosurgeon to hand over intubated and sedated — make it a decision, not a default.

The one you are not evacuating - Small, minimally symptomatic EDHs are managed with serial neurologic exams and a repeat head CT within 6 to 8 hours. If you anesthetize one of these for an unrelated injury, you have removed the exam that is the entire monitoring plan. Say that out loud to the team before you start.

An epidural hematoma (EDH) is blood collecting in the potential space between the dura and the inner table of the skull. The dura's attachment at the sutures confines it, which is why it looks biconvex on CT and does not cross suture lines. Most come from arterial bleeding off a branch of the middle meningeal artery beneath a fracture of the squamous temporal bone — a skull fracture is present in 85% to 95% of cases — while up to 10% are venous from a torn dural sinus. EDH complicates about 2% of head injuries and up to 15% of fatal head trauma.

The classic loss of consciousness, lucid interval, then rapid deterioration shows up in only 14% to 21% of patients. Because the vault is fixed, an expanding clot raises ICP, drives cerebral perfusion pressure down (CPP = MAP - ICP), and ends in uncal herniation.