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Subsections
Subdural Hematoma

Head Trauma

Subdural Hematoma

Background

  1. Definition
    • Abnormal collection of blood under the dura mater (subdural space)
  2. Synopsis
    • Blood that forms between the dura and the brain (View Video)
    • Usually caused by movement of brain relative to skull
      • Acceleration-deceleration injuries
    • More common than epidural hematomas
      • Up to 30% of patients with severe head trauma

Pathophysiology

  1. Mechanism
    • Rupture of bridging veins leading to blood accumulating within subdural space
  2. Etiology/Risk Factors
    • Blunt/shearing injuries
    • Cranium extraction devices used during delivery
    • Head injury
      • Accidental
      • Intentional
        • Shaken baby syndrome
  3. Epidemiology
    • Incidence/Prevalence
      • Children
        • < 2 years of age: 13 cases/100,000 child-years
        • < 1 year of age: 21 cases/100,000 child-years
      • Abusive head trauma
        • 17 cases/100,000 child-years (Europe and USA)
    • Morbidity/Mortality
      • Rates of 30-80% have been reported
      • Survivors may not fully regain functioning

Classification

  1. Acute subdural
    • Symptomatic within 24 hrs of trauma
    • Mortality
      • 60% if untreated
      • 30% if surgically repaired in < 4hrs
  2. Sub-acute subdural
    • Symptomatic 24 hrs- 2 weeks after injury
    • Most patients require surgical evacuation of the subdural
  3. Chronic subdural
    • Symptomatic > 2 weeks after trauma
    • Up to 45% re-bleed
    • Require surgery if symptomatic
    • Mortality
      • 10%
      • Greatest in elderly
  4. Posterior fossa subdural
    • Very rare
      • < 1 %
    • On CT: does NOT cross the midline
    • VERY poor prognosis
    • Survival < 5%

Diagnostics

  1. History/Symptoms
    • Contradiction concerning injury and history given by caretaker
    • Traumatic birth
      • Forceps use
      • Vacuum extraction devices
    • Caretaker reports
      • Abnormal breathing patterns
      • Apneic episodes w/ changes in behavior
      • Vomiting
      • Abnormal movements
      • Seizures
    • Description of injury (Patient, witnesses, EMS)
    • ETOH/ substance abuse
    • Prior neuro problems
    • Medications
      • Anticoagulants
  2. Physical Exam/Signs
    • Mental status changes
    • External injury to scalp
      • Cephalohematoma (visible or palpated)
      • Infant: open fontanel results in
        • Palpation revealing tense, non-compliant or bulging
        • May see abusive trauma from skin in form of bruising or limb deformities
    • May see no external visual injury on physical exam
    • If patient unconscious at time of trauma
      • Prognosis is poor
      • Usually have concurrent DAI
    • Clinical Findings
      • Acute subdural
        • Head trauma with decreased consciousness (see GCS (Open Calc))
          • May see lucid interval (50-70%)
          • Mental status then declines
          • Pupil inequality
          • Motor deficits
          • Signs of increased ICP
            • Lethargy
            • Hypertension
            • Papilledema
            • Emesis
            • Cushing reflex (pre-terminal)
      • Subacute subdural
        • May have non-specific complaints
          • Headache
          • Lethargy
          • Decreased concentration
          • Mild mental status changes
          • Muscle weakness
          • Paralysis
          • Symptoms of increased ICP
            • Lethargy
            • Hypertension
            • Papilledema
            • Emesis
            • Cushing reflex (pre-terminal)
      • Chronic subdural
        • May have subtle/ nonspecific complaints
          • Headache
          • Altered mental status (50%)
          • Subtle personality change
          • Seizures
          • Focal neuro dysfunction
          • Unilateral weakness/ hemiparesis (45%)
          • Symptoms of increased ICP
            • Lethargy
            • Hypertension
            • Papilledema
            • Emesis
            • Cushing reflex (pre-terminal)
  3. Labs/Tests
  4. Imaging
    • CT head
      • Acute subdural
        • Usually hyperdense
        • Usually crescent-shaped
        • Lies between calvarium and cortex
        • Can extend beyond suture lines
        • May follow contour of calvarium
        • May be seen in interhemispheric fissure
      • Subacute/chronic subdural
        • May appear isodense or hypodense
        • Contrast may enhance this
        • May see indirect evidence of subdural
          • Midline shift
          • Effacement of ipsilateral cortical sulci
          • Compression of ventricles
      • Posterior fossa subdural
        • Does NOT cross the midline
        • Does NOT extend above the tentorium
    • MRI brain
      • If time permits/risk of sedation mitigated
      • Reveals imaging of brain w/ subtle changes including brain stem
      • Help in aging of the subdural hematoma
  5. Differential Diagnosis
    • Hydrocephalus ex vacuo
    • Ischemic stroke
    • Intracranial neoformation
    • Epidural hematoma
    • Posttraumatic subdural hygroma
    • Subdural empyema
    • Subdural effusion
    • Meningioma
    • Meningeal metastasis
    • Traumatic brain injury

Treatment

  1. Initial/Prep/Goals
    • ABCs, IV access, monitor
    • Intubation (presume elevated ICP)
    • Fluid resuscitation to treat shock
    • Spine precautions
    • Survey for additional injuries
      • Chest, abdomen
      • Spine, extremities
    • Treat elevated ICP
    • Treat Seizures
      • Acute seizures:
        • Lorazepam: 1 to 2 mg IV q 5 min up (max :4 mg)
        • Diazepam (0.1 mg/kg IV (up to 5 mg) q 5 minutes (max: 20 mg)
      • Long-term or prophylactic Tx:
        • Phenytoin:
          • Load: 15-20 mg/kg IV (give at < 50 mg/min)
          • May follow with 100-150 mg after 30 min
  2. Medical/Pharmaceutical
  3. Surgical/Procedural
    • Surgical evacuation
    • Burr hole drainage
      • Preferred in pts w/ neurological symptoms
  4. Further treatment
    • Optimize cerebral perfusion
    • Treat systemic shock
    • Treat hypoxia
    • Good general medical care
    • Monitor ICP and arterial pressure
      • Keep ICP < 20
      • Keep CPP < 70
    • Repeat head CT as needed

Disposition

  1. Admission criteria
    • OR for evacuation
      • Acute subdural
      • Most symptomatic sub-acute or chronic subdural
    • ICU observation with ICP monitoring
      • Small, stable subdural
  2. Consult(s)
    • Neurology, neurosurgery, pediatric neurologist and radiology as necessary
  3. Discharge/Follow-up Instructions
    • Outcome varies
    • Prognosis is dependent on extent of brain injury
    • Follow-up per care team orders
    • Pt should be educated on
      • Their specific prognosis and care that is needed for optimal quality of life
      • Social workers (navigate complex social/legal aspects of abusive injury)

Nursing Considerations

  1. Be attentive to pulmonary care and endotracheal suctioning
  2. Careful ICP monitoring
  3. Monitor VS every 2 hrs or as needed
  4. Careful I/O
  5. Frequent neuro exams, every 2 hrs or as needed
    • Changes in pupil size and reactivity
    • Alterations in VS
    • Changes in resp rate, depth, or pattern, may indicate brain stem compression
  6. For high-risk pts, admin of analgesics or intratracheal lidocaine to attenuate cough reflex and response to noxious stimuli may be appropriate
  7. Space stimuli incl nursing care activities, peripheral venipuncture, and repositioning, over time to limit a cumulative effect on increasing ICP
  8. Maintain head in neutral position
  9. HOB to 30 degrees at all times (per institution protocol)
    • Reverse Trendelenburg if HOB elevation contraindicated
  10. Care of pt with subdural drain
    • Expect drainage to resemble motor oil
    • Drain must be kept below level of head, check physician order
    • Drainage should occur over 24-48 hrs
    • Record vol and time intervals of drainage
    • Observe for clots or kinks in tubing that will prevent drainage
    • Keep dressing dry and intact
    • Prevent pulling or tension on tubing
  11. Keep pt warm
  12. Provide emotional and spiritual support for family
    • Offer social services as needed
    • Support family in decisions about long term care or withdrawal of care
  13. Explain to family the procedure for intracranial surgery
  14. Prepare for emergency surgery as needed
  15. Nursing dx
    • Risk for fluid vol imbalance
    • Alteration in mobility
    • Risk for ineffective breathing pattern
    • Ineffective cerebral tissue perfusion

References

  1. Biros MH, Heegaard W. Head Injuries. In: Marx (ed); Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed; 2002. Mosby pp 286-314
  2. Bullock R, Chesnut R, Clifton G: Guidelines for the management of severe head injury. Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care. J Neurotrauma 1996 Nov; 13(11): 641-734
  3. Marion DW: Management of traumatic brain injury: past, present, and future. Clin Neurosurg 1999; 45: 184-91
  4. Evans RW, Wilberger JE.Traumatic Disorders: In:Goetz: Textbook of Clinical Neurology, 2nd ed.,2003 Saunders pp 1134-1135
  5. Croce MA, Dent DL, Menke PG, et al: Acute subdural hematoma: nonsurgical management of selected patients. J Trauma 1994 Jun; 36(6): 820-6; discussion 826-7
  6. Cooper PR: Traumatic intracranial hematomas. In Wilkins RH, Rengachary SS, editors: Neurosurgery, New York, 1985, McGrawHill.
  7. Laldjising ER, Cornelissen FM, Gadjradj PS. Practice variation in the conservative and surgical treatment of chronic subdural hematoma. Clinical Neurology and Neurosurgery. Aug 2020;195
  8. Subdural Hematoma. StatPearls [Internet]. Available at: https://www.ncbi.nlm.nih.gov/books/NBK532970/. [Accessed October 2022]
  9. Iliescu IA. Current diagnosis and treatment of chronic subdural haematomas. J Med Life. 2015;8(3):278-284.
  10. VisualDx. Subdural Hematoma. Available at: https://www.visualdx.com/visualdx/diagnosis/subdural+hematoma?diagnosisId=53161&moduleId=101#References. [Accessed October 2022]
Contributor(s)
  1. Singh, Ajaydeep, MD
Updated/Reviewed: October 2022