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Epidural hematoma

Terms in this set (21)

Overview
Collection of blood in the potential space between the dura and skull bone, occurring intracranially (most commonly in the temporoparietal area) or intraspinally (most commonly in the thoracic spine)
Acceleration-deceleration or coup-contrecoup injuries that disrupt normal nerve functions in bruised area and cause intracranial bleeding
Classified as acute, subacute, or chronic
Overview-Pathophysiology
Injury occurs directly beneath the site of impact when the brain rebounds against the skull from the force of a blow (a beating with a blunt instrument, for example), when the force of the blow drives the brain against the opposite side of the skull, or when the head is hurled forward and stopped abruptly (as in an automobile accident when a driver's head strikes the windshield).
The brain continues moving and slaps against the skull (acceleration), then rebounds (deceleration). The brain may strike bony prominences inside the skull (especially the sphenoidal ridges), causing intracranial hemorrhage or hematoma that may result in tentorial herniation.
The periosteal dura separates from the bone, and vessels are disrupted due to shearing forces.
A hematoma rapidly expands if there is compromise to arterial or venous structures.
Overview-Causes
Anticoagulation
Coagulopathy or bleeding diathesis
Disk herniation
Epidural anesthesia
Lumbar puncture
Hepatic disease with portal hypertension
Hypertension
Lumbar puncture
Paget's disease of bone
Skull fracture
Thrombolysis
Trauma
Valsalva's maneuver
Vascular malformation
Overview-Incidence
Epidural hematoma in the brain is rare in patients older than age 60.
It's four times more common in men than in women.
It occurs approximately 2% of all cases of head trauma.
Spinal epidural hematoma peaks during the fifth and sixth decades.
Overview-Complications
Neurologic deficits
Postconcussion syndrome
Increased intracranial pressure (ICP)
Seizures
Spasticity
Neuropathic pain
Respiratory depression
Assessment-History
Injury to the head or spine (such as lumbar puncture or epidural anesthesia)
Headache
Nausea
Change in mental status
Weakness or numbness (spinal epidural hematoma)
Assessment-Physical Findings
Head wound, contusion, or laceration
Vomiting
Neurologic signs based on the extent of bleeding—dilated pupils, weakness, sensory deficits, alterations in reflexes, alterations in bladder or anal sphincter tone, and focal neurologic deficits (aphasia, visual field defects, numbness, ataxia)
Bradycardia and hypertension (with increased ICP)
Otorrhea or rhinorrhea (with skull fracture that disrupts the dura)
Unilateral or bilateral weakness (with spinal epidural hematoma)
Urinary or fecal incontinence (with spinal epidural hematoma)
Diagnostic Test Results-Laboratory
Coagulation studies show clotting abnormalities (if cause is anticoagulation).
Diagnostic Test Results-Imaging
Skull X-rays may reveal a fracture.
Myelography may show a space-occupying mass.
Computed tomography scan or magnetic resonance imaging identifies abnormal masses or structural shifts within the cranium.
Treatment-General
Supportive: airway, breathing, and circulation
Wound care
Head of the bed elevated 30 degrees with intracerebral injury
Treatment-Diet
Based on extent of injury
Nothing by mouth if surgery necessary
Caloric supplementation
Treatment-Activity
Bed rest initially, then progressive activity as tolerated
Treatment-Medications
Vitamin K, fresh frozen plasma, platelets, or clotting products (if coagulation study results are abnormal)
Analgesics (after extent of injury is determined)
Osmotic diuretics such as mannitol I.V., to reduce intracranial pressure
Anticonvulsants, such as phenytoin or fosphenytoin
Prophylactic antibiotics if appropriate
Corticosteroids, such as methylprednisolone, if spinal cord compression is involved
Histamine-2 receptor antagonists, such as famotidine, for gastric ulcer prophylaxis
Acetaminophen for fever
Treatment-Surgery
Placement of burr holes
Evacuation of the hematoma
Craniotomy
Nursing Considerations-Nursing Diagnoses
Acute pain
Compromised family coping
Decreased cardiac output
Impaired physical mobility
Impaired skin integrity
Impaired tissue integrity
Ineffective coping
Post-trauma syndrome
Risk for ineffective cerebral tissue perfusion
Risk for injury
Nursing Considerations-Expected Outcomes
express feelings of increased comfort and pain relief
use support systems to assist with coping
maintain adequate cardiac output and hemodynamic stability
recover or be rehabilitated from physical injuries to the greatest extent possible
experience lesion and wound healing without complications
maintain tissue integrity
demonstrate adaptive coping behaviors
express feelings and fears about the traumatic event
exhibit signs of adequate cerebral perfusion
sustain no further harm or injury.
Nursing Considerations-Nursing Interventions
Assess neurologic status closely for changes; check papillary response and report any changes.
Provide appropriate wound care as indicated.
Give prescribed drugs; ensure patent I.V. access for drug administration as indicated.
Ensure a patent airway. Anticipate respiratory support if breathing is compromised; prepare for intubation and mechanical ventilation if the patient's respiratory status deteriorates.
Cluster nursing activities to provide adequate rest. Institute energy conservation measures to minimize fatigue and energy expenditure.
Elevate the head of the bed approximately 30 degrees to prevent increased ICP.
Reposition the patient at least every 2 hours while on bed rest.
Provide meticulous skin care, especially to pressure areas.
Check drainage from the nose or ear for evidence of glucose, which suggests cerebrospinal fluid (CSF) leakage.
Provide passive range-of-motion exercises during the acute period to maintain joint function.
Provide emotional support. Allow the patient and family to verbalize concerns and feelings; assist with positive coping strategies.
Institute seizure precautions.
Nursing Considerations-Monitoring
Vital signs
Neurologic status, including signs and symptoms of increased ICP
Wound appearance, including signs of healing
Seizure activity
Respiratory status
Nursing Considerations-Associated Nursing Procedures
Blood pressure assessment
IV bag preparation
IV bolus injection
IV catheter insertion
Incontinence management, fecal
Incontinence management, urinary
Intracranial pressure monitoring
Lumbar puncture, assisting
Neurologic assessment
Oral drug administration
Pain management
Passive range-of-motion exercises
Postoperative care
Preoperative care
Preparing a patient for neurologic surgery, OR
Pressure ulcer prevention
Pulse oximetry
Pulse assessment
Respiration assessment
Seizure management
Surgical wound dressing application
Venipuncture
Patient Teaching-General
disorder, diagnosis, and treatment, including the need for possible surgical evacuation of the hematoma or use of burr holes to help relieve increased ICP
risk of postconcussion syndrome, which may last hours to months
prescribed medications, including the use of anticonvulsants for seizure prophylaxis
adverse effects of prescribed medications
signs and symptoms indicating a change in neurologic status and increased ICP, including the need to notify a practitioner if any occur
signs and symptoms of postconcussion syndrome, such as headache, dizziness, vertigo, restlessness, emotional lability, inability to concentrate, and fatigue, and the importance of notifying a practitioner if any occur
need to avoid aspirin as a pain treatment
need to observe for signs of CSF drainage
signs and symptoms of infection and the need to notify a practitioner if any occur
general preventive measures, such as use of seat belts and protective gear.
Patient Teaching-Discharge Planning
Refer the patient to physical, occupational, and speech therapy, as appropriate.
Refer the patient to social service for extended services, as appropriate.
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