Traction

1. Institute of Health Science
Department of Nursing
Postgraduate Program of Adult Health Nursing
Subdural Hematoma Seminar Presentation
Set By: Rebira Workineh (AHN Student)
Rebira W. ( AHN student)
13 December 2023
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2. Table of Contents
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 Introduction
 Epidemiology
 Types of SDH
 Pathophysiology
 Etiology
 Clinical manifestations
 Investigations
 Differential diagnosis
 Medical management
 Nursing care plan
 Complication
 Prevention
 Prognosis
 References

3. Introduction
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Definition
 A SDH is a collection of blood that forms in the subdural space, the space between
the dura mater and the arachnoid mater but external to the brain and arachnoid
membrane.
 It is the most common type of traumatic intracranial mass lesion
 The brain has three membrane layers called meninges that lie between the bony
skull & the brain tissue

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5. Introduction Cont’d…
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 A client with SDH may be experienced a tear in a blood vessel, most commonly in a
vein & blood is leaking out of the torn vessel into the space below the dura mater
membrane layer
 Bleeding into this space is called a subdural hemorrhage, other names of SDH
 Subdural hemorrhage
 Intracranial hematoma
 More broadly, it is also a type of traumatic brain injury
(Pierre L, et al, 2021)

6. Epidemiology
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 A study revealed that acute SDH have been reported to occur in 5-25% of patients
with severe head injury
 The annual incidence of chronic SDH has been reported to be 1-5.3 cases per
100,000 population
 Acute SDHs are more common in men than in women with a M-F ratio of 3:1
 Chronic SDH has also a higher incidence in men than women with M-F ratio of 2:1
 The incidence of chronic SDH appears to be highest in the 50th through 70th of life

7. Reasons For Variation
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 Cranial size: Contribute to pathogenesis or risk factor
 Great exposure of males to injury
 Men sustain nearly 2 to 3 times as many brain injury as women
 Estrogen effect on the capillaries
 Increase the level of procoagulation factors, reduce anticoagulant factors
 Fewer medical visit of females
(Jae-sang Oh, et al, 2014)

8. Types of SDH
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SDH may be:
 Hyperacute SDH-Within 24 hours
 Acute SDH- Within 48-72 hours
 Sub-acute SDH- Within 3-21 days
 Chronic SDH- Within 3 wks. to months

9. Types Cont’d…
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 Acute SDH is commonly associated with extensive primary brain injury.
 A study revealed that 82% of comatose patients with acute SDH had parenchymal
contusions.
 Acute SDH is the most common type of traumatic intracranial hematoma, occurring
in 24% of patients who present comatose.
(Kotwica Z, et al, 1993)

10. Pathophysiology
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Bleeding in a SDH occurs from tearing of the bridging veins that cross from the
cortex to the dural venous sinuses, which are vulnerable to deceleration injury
This subsequently leads to accumulation of blood between the dura and arachnoid
and results in a gradual rise in intracranial pressure
This can lead to herniation and brainstem death if left untreated

11. Etiology
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 Head trauma
 Coagulopathy
 Medical anticoagulation (e.g., warfarin, heparin)
 Hemophilia
 Liver disease
 Thrombocytopenia

12. Etiology Cont’d…
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 Non-traumatic intracranial hemorrhage
 Hypertension (most common)
 Cerebral aneurysm
 Arterio-venous malformation
 Tumor (meningioma or dural metastases)
 Postsurgical
 Craniotomy
 CSF shunting

13. Etiology Cont’d…
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 Intracranial hypotension
 After lumbar puncture
 Lumbar CSF leak
 Lumbo-peritoneal shunt
 Spinal epidural anesthesia
 Shaken baby syndrome
 Spontaneous or unknown-rare
(Mashour GA, et al, 2006 )

14. Clinical Manifestations
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 Headache (doesn’t go away, more severe in acute SDH)
 Confusion and drowsiness
 Nausea & vomiting
 Slurred speech & changes in vision
 Dizziness, loss of balance, difficulty walking
 Weakness of one side of the body

15. Clinical Cont’d…
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 Memory loss, disorientation, & personality changes (older adults with chronic SDH)
 Enlarged head in babies (as blood collects)
 As bleeding continues & the pressure in the brain increases, symptoms can get
worse, symptoms at this point include:
 Paralysis
 Seizures
 Breathing problems
 Loss of consciousness

16. Investigations
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 Initial routine bloods, including FBC, CRP, U & Es, LFTs
 PT & PTT→help in assessing for differential diagnosis
 CT scan is the gold-standard initial imaging modality for a suspected SDH
 A skull plain film radiograph- Pediatrics
(Mehta V, et al, 2023)

17. Temporal Changes on CT Imaging
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 Subdural hematomas will appear differently on CT imaging
 Acute-diffusely hyperdense
 Subacute-heterogeneously hyperdense or isodense
 Chronic SDH-diffusely hypodense
(Mehta V, et al, 2023)

18. Differential Diagnosis
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(Mehta V, et al, 2023)
For acute SDH
 Extradural hematoma
 Subarachnoid hemorrhage
 Intracerebral hemorrhage
 Intracerebral infarction
For Chronic SDH
 Space occupying lesions
 Meningitis
 Encephalitis
 Dementia

19. Medical Management
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 In an acute setting, do initial systematic A to E assessment
 Elevated ICP should also be managed appropriately
 Reversing anticoagulation appropriately
 Start anti-epileptic medications for 1 week after presentation of a SDH
 A SDH following a fall, investigate for potential underlying reasons for falls

20. Definitive Management
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 Depend on the size & clinical features
 Not all cases require surgery
 Conservative management is generally appropriate for small acute SDH
 A surgical intervention called a trauma craniotomy flap required for an acute
SDH- a large opening in the skull is created to evacuate the hematoma and
relieve the associated mass effect

21. Definitive Cont’d…
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 For large acute SDHs, there is often a significant mass effect present,
therefore the bone flap is often left out at surgery, termed a decompressive
craniectomy
 For chronic SDH, surgical intervention can be either a burr hole craniotomy
with irrigation or a twist-drill craniotomy with drain placement- reduce
recurrence rate & mortality without complications

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Nursing Care Plan for SDH

23. Nursing Assessment
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1. Neurological assessment
 Do Glasgow coma scale
 Monitor pupillary response, assess change in size & reactivity
 Assess for motor strength and coordination
 Observe signs of neurological deterioration, such as changes in mental status,
restlessness, or posturing

24. Nursing Cont’d…
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2. Vita Signs, oxygen therapy
 Monitor vital signs, BP, PR, RR, To, pain & PSO2
 Observe signs of increased ICP, such as ↑BP & bradycardia
3. Head injury assessment
 Assess mechanism of injury, time of occurrence, & any loss of consciousness
4. Pain assessment
 Assess pain using a pain scale, as head injuries can be painful & uncomfortable
 Note the location, intensity, & quality of the pain reported by the patient

25. Nursing Cont’d…
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5. Respiratory assessment
 Evaluate the patient’s respiratory status and auscultate lung sounds for any signs of
aspiration or respiratory distress
 Assess for any signs of compromised airway or breathing difficulties
6. Gastrointestinal Assessment
 Monitor if client has nausea & vomiting, can be associated with increased ICP

26. Nursing Cont’d…
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7. Mental health assessment
 Assess the patient’s emotional state
 Provide emotional support during the assessment process
 Observe for signs of anxiety, confusion, or emotional distress
8. Medication and allergy review
 Obtain a list of the patients’ current medications & any known allergies
 Review medications that may affect clotting or increase the risk of bleeding

27. Nursing Cont’d…
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9. Past medical history
 Gather information if the client had any previous head injuries or bleeding disorders
10. Family history
 Inquire about a family history of bleeding disorders & neurological conditions

28. Nursing Diagnoses
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 Acute Pain R/T the head injury and SDH
 Impaired verbal communication R/T potential aphasia, dysarthria, or altered mental
status resulting from the SDH
 Anxiety R/T the uncertainty of the head injury’s outcome and the presence of the
SDH
 Impaired Physical Mobility R/T neurological deficits and decreased muscle strength
secondary to the SDH

29. Nursing Cont’d…
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 Risk for decreased Intracranial adaptive capacity R/T the presence of a SDH causing
increased ICP and potential compression of brain tissue
 Risk for Ineffective cerebral tissue perfusion R/T compromised blood flow and
oxygenation caused by the SDH
 Risk for Infection R/T the possibility of surgical interventions to manage the SDH

30. Nursing Interventions
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1. Neurological Monitoring
 Frequently assess level of consciousness, cognitive function, & pupillary responses
 Document Glasgow coma scale scores regularly to track changes in neurological status
2. Managing Pain
 Administer prescribed analgesics promptly to relieve pain and discomfort
 Use non-pharmacological pain relief measures such as positioning, or relaxation exercises

31. Nursing Cont’d…
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3. Mobilizing and Positioning
 Safe and controlled mobilization
 Appropriate positioning, maintain the head of the bed elevated to reduce ICP & optimize
cerebral perfusion
4. Monitoring &managing ICP
 In collaborate with the healthcare team, monitor ICP readings, maintain a calm environment
 Minimize environmental stimuli, avoid activities that increase intrathoracic pressure

32. Nursing Cont’d…
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5. Preventing infection
 Strict aseptic techniques during wound care & invasive procedures to reduce the risk of
infection.
 Provide prescribed antibiotics
6. Managing skin integrity
 Prevent pressure ulcers, such as frequent repositioning, the use of pressure-relieving
devices, and regular skin assessments
 Keep the skin clean & dry

33. Nursing Cont’d…
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7. Reducing anxiety
 Address any concerns related to head injury and SDH
 Utilize relaxation techniques to help the patient cope with anxiety & promote a
sense of calm
(Arslan Sarwar, et al, 2023)

34. Complication
 If left untreated, coma and death
 Brain herniation
 Recurrent hematoma formation
 Seizures
 Raised ICP
 Cerebral edema
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35. Prevention
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 Hematoma inevitable as a result of an accident, but the risks can be reduced
 Protecting your head
 Resting after a head injury
 Removing tripping hazards from the home
 Having vision checked regularly to prevent falls & accidents
 Having your healthcare provider do a medication review
 Drinking responsible
 Being careful when taking blood thinners

36. Prognosis
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 Prognosis depends on:
 Age
 The severity of head injury and how quickly the client received treatment.
 About 50% of people with large acute SDH survive though permanent brain damage often occurs as a
result of the injury
 Younger people have a higher chance of survival than older adults
 People with chronic SDH usually have the best prognosis
 Older adults have an increased risk of developing another hemorrhage after recovering from a
chronic SDH

37. References
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1. Mashour GA, et al, (2006 ). Intracranial subdural hematoma and cerebral
herniation after labor epidural with no evidence of dural puncture. Anesthesiology.
2. Chen JC, et al, (2000). Causes, epidemiology, & risk factors of chronic subdural
hematoma, Neurosurgery clinics of North America.
3. Arslan Sarwar, et al, (2023). Nursing Care Plans.
4. Kotwica Z, et al, (2018). Acute Subdural Hematoma in adults: an analysis of
outcome in comatose patients.

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MAY GOD BLESS YOU!