Mr. K, an elderly male, presented to the emergency room via taxi with a head wound. He reported falling off his bicycle and hitting his head. His vitals and examination were notable for elevated blood pressure. He was given pain medication and instructed to get a head CT scan. After waiting for several hours, he began vomiting and his condition deteriorated. A repeat examination showed decreased responsiveness. The CT scan identified an epidural hematoma, a collection of blood between the skull and dura that results from head trauma. The case discusses the management of traumatic brain injuries like epidural hematomas through airway control, imaging, and transfer to higher level care when needed.

1. Dr ERROL WILLIAMSON
September 20,2017

2. CASE HISTORY
• AN ELDERLY MALE(MR K) WAS FOUND BY THE ROADSIDE OFF MANDELLA HIGHWAY WITH A
WOUND TO HIS HEAD AND WAS PLACED IN A TAXI AND WAS BROUGHT TO THE
EMERGENCY ROOM.
• HE HAD A BLOOD STAINED HANDKERCHIEF WRAPPED AROUND HIS HEAD.
• HE DENIES ANY LOC AND STATES THAT HE HAD SUSTAINED A FALL FROM HIS BICYCLE AND
HIT HIS HEAD AND RIGHT SHOULDER AFTER THE BICYCLE WENT DOWN INTO A
POTHOLE.
• VITALS BP 172/98 HR 82 RR 18 SPO2 96%, GMR 5.6MMOL
• ESI 1 ES1 2 ESI 3 ESI 4 ESI 5

3. CASE
HISTORY
He was sent to the screening room
doctor with a c-collar and was given an
ESI level 4, got his wound dressed and
was told to wait in the waiting area.
After waiting for 6 hours to be seen, he
got miserable and the customer service
rep found out that he was a CNA case.
When he was finally called, he was seen
by a doctor in room 3 and was sent to
the xray department.

4. HISTORY
• UPDATED HISTORY:
• H/0 HTN OFF MEDS FOR A YEAR, HE STATES THAT HE HAD NIL LOC AFTER THE FALL.
NIL ENT BLEED, NIL VOMITING, MILD HEADACHE, SLIGHT DIZZINESS
PMH: NIL
PSH: NIL
DH: NIL NKDA
FH: NIL KNOWN
SH: DRINKS ALCOHOL FOR SEVERAL YEARS (ADMITS THAT HE HAD A DRINK EARLY THIS
MORNING) NIL SMOKING HISTORY

5. EXAMINATION
NIL DISTRESS, MM= PINK + MOIST, ANICTERIC, AFEBRILE
• RS- CHEST CLINICALLY CLEAR
• CVS- S1, S2, NIL MURMURS
• ABD- SOFT FLAT NON-TENDER, NIL ORGANOMEGALLY
• CNS- AWAKE ALERT ORIENTED TIME, PLACE, PERSON
• PUPILS??? NIL GROSS FOCAL CRANIAL NERVE DEFICITS…..NIL ENT BLEED VISIBLE
• GCS 15/15, POWER 5/5 THROUGHOUT
• MSK: 8CM LACERATION NOTED TO SCALP HAEMATOMA STABLE, NIL OTHER SIGNS NOTED

6. • ASSESSMENT: LACERATION TO SCALP , R/O SKULL FRACTURE
• PLAN:
• C&D WOULD
• DT 05CC IM STAT
• PANADOL 1G PO STAT
• SKULL XRAY
• SUTURE LACERATION POST XRAY

7. CASE
HISTORY
After 40mins of waiting at the Xray
department, the porter was
instructed to take the patient to
the emergency room after he
started vomiting and appeared
droopy.
Vitals BP 202/123 HR 56 RR 8
irregular, Spo2 88% GMR 4.8
Responsiveness to Pain

8. GCS
EYES open to pain
occasionally
Heard Muttering a sound

9. DISCUSSION

10. LAYERS OF THE BRAIN

11. EPIDURAL HAEMORRHAGE

12. EPIDURAL HAEMORRHAGE
•EPIDURAL HAEMORRHAGE (EDH) IS A TRAUMATIC
ACCUMULATION OF BLOOD BETWEEN THE POTENTIAL
SPACE OF THE INNER TABLE OF THE SKULL AND THE
STRIPPED-OFF DURAL MEMBRANE. EDH RESULTS FROM
TRAUMATIC HEAD INJURY, USUALLY WITH AN
ASSOCIATED SKULL FRACTURE AND ARTERIAL LACERATION.

13. LOCATION
•APPROXIMATELY 70-80% OF ARE LOCATED IN THE TEMPORO-
PARIETAL REGION
•FRONTAL AND OCCIPITAL EDH EACH CONSTITUTE ABOUT 10%
•EDH ARE USUALLY ARTERIAL IN ORIGIN, HOWEVER IT CAN
RESULT FROM TORN VENOUS SINUSES
•INTRACRANIAL EDH IS RARE IN CHILDREN <2YRS
•IT IS RARE IN PERSONS >60YRS AS THE DURA IS TIGHTLY
ADHERENT TO THE CALVARIUM

15. PRESENTATION
BLUNT TRAUMA TO THE HEAD, FOLLOWED BY:
1) INITIAL CONFUSION, DECREASED CONSCIOUSNESS, OR LOSS OF CONSCIOUSNESS
2) A “LUCID INTERVAL” (20-50%):
• A BRIEF PERIOD OF FULL CONSCIOUSNESS/RESTORED MENTAL STATUS. THE PATIENT
SEEMS BACK TO HIS/HER “NORMAL SELF.”
3) CHANGE IN MENTAL STATUS +/- UNSTABLE VITAL SIGNS (BLOOD PRESSURE, HEART
RATE):
• THE PATIENT BECOMES CONFUSED, SOMNOLENT (SLEEPY), MAY HAVE NEUROLOGIC
SIGNS SUCH AS HEMIPARESIS, ONE DILATED PUPIL, MAY BECOME COMATOSE.

16. OTHER PRESENTATION
•HEADACHE
•NAUSEA/VOMITING
•SEIZURES
•FOCAL NEUROLOGICAL DEFICITS

18. SUBDURAL HAEMORRHAGE

19. A SUBDURAL HAEMORRHAGE IS A COLLECTION OF
BLOOD ACCUMULATING IN THE SUBDURAL SPACE, THE
POTENTIAL SPACE BETWEEN THE DURA AND ARACHNOID
MATER OF THE MENINGES AROUND THE BRAIN
•ACUTE SDH (UP TO 7 DAYS)
•SUB ACUTE SDH (7-21 DAYS)
•CHRONIC SDH (MORE THAN 21 DAYS)

20. RISK FACTORS
•EXTREME OF AGE
•ANTICOAGULANTS USAGE
•LONG TERM ALCOHOL ABUSE

21. •BLOOD TENDS TO COLLECT MORE SLOWLY THAN IN
EPIDURAL HAEMATOMA BECAUSE OF ITS VENOUS
ORIGIN. HOWEVER, SUBDURAL HEMATOMA IS OFTEN
ASSOCIATED WITH OTHER BRAIN INJURIES AND
UNDERLYING PARENCHYMAL DAMAGE.

22. PRESENTATION
•A RECENT HISTORY OF HEAD TRAUMA WITH:
HEADACHE, HEMIPARESIS, ALTERED/FLUCTUATING LEVELS OF
CONSCIOUSNESS, AGITATION, DISORIENTATION ,DIZZINESS, PERSONALITY
CHANGES LETHARGY, ETC
•OCCASIONALLY SPONTANEOUS ACUTE SUBDURAL HAEMATOMAS ARE SEEN
WITH AN UNDERLYING BLEEDING DISORDER (E.G. ANTICOAGULATION
MEDICATION, THROMBOCYTOPENIA) OR STRUCTURAL ABNORMALITY

25. SUBARACHNOID HAEMORRHAGE

26. •SUBARACHNOID HAEMORRHAGE (SAH) REFERS TO EXTRAVASATION OF
BLOOD INTO THE SUBARACHNOID SPACE BETWEEN THE PIA AND
ARACHNOID MEMBRANES.
•IT CAN OCCUR VIA TRAUMATIC OR NON-TRAUMATIC CAUSES
•PATIENTS WHO RECEIVE A TRAUMATIC SAH HAVE AN INCREASED RISK OF
MORTALITY VS THOSE WHO SUSTAIN A NON-TRAUMATIC SAH

27. •OF NON-TRAUMATIC SUBARACHNOID HAEMORRHAGES, THE MAJORITY
ARE DUE TO A RUPTURED BERRY ANEURYSM.
•RISK FACTORS FOR SUBARACHNOID HEMORRHAGE
• HYPERTENSION
• SMOKING
• EXCESSIVE ALCOHOL CONSUMPTION
• POLYCYSTIC KIDNEY DISEASE
• FAMILY HISTORY OF SUBARACHNOID HEMORRHAGE
• COARCTATION OF THE AORTA
• MARFAN SYNDROME
• ETC

28. PRESENTATION
• PATIENTS TYPICALLY PRESENT WITH A THUNDERCLAP HEADACHE, USUALLY THE WORST
HEADACHE OF THEIR LIVES; A SEVERE HEADACHE OF ACUTE ONSET THAT REACHES MAXIMAL
INTENSITY WITHIN MINUTES.
• IT IS OFTEN ASSOCIATED WITH PHOTOPHOBIA AND MENINGISM. IN A SUBSTANTIAL NUMBER OF
PATIENTS (ALMOST HALF), IT IS ASSOCIATED WITH COLLAPSE AND LOSS OF CONSCIOUSNESS.
• THEY MAY ALSO PRESENT WITH NAUSEA OR VOMITING , SEIZURES, DIPLOPIA FOCAL
NEUROLOGICAL DEFICITS OFTEN PRESENT EITHER AT THE SAME TIME AS A HEADACHE OR
SOON THEREAFTER .

29. GRADING SCALE OF SAH
• SURVIVAL CORRELATES WITH THE GRADE
OF SUBARACHNOID HAEMORRHAGE UPON
PRESENTATION. REPORTED FIGURES
INCLUDE A 70% SURVIVAL RATE FOR HUNT
AND HESS GRADE I, 60% FOR GRADE II,
50% FOR GRADE III, 40% FOR GRADE IV,
AND 10% FOR GRADE V.

31. MANAGEMENT
THE MAINSTAY IS TO PREVENT FURTHER SECONDARY BRAIN INJURY, TO IDENTIFY
TREATABLE MASS LESIONS, AND TO IDENTIFY OTHER LIFE-THREATENING INJURIES

32. PRIMARY SURVEY
Airway
maintenance
with c-spine
stabilisation
Breathing &
ventilation
Circulation with
haemorrhage
control
Disability
Exposure &
environmental
control
Adjuncts

33. AIRWAY MAINTENANCE WITH C-SPINE STABILISATION
• IF THE PATIENT IS ABLE TO COMMUNICATE VERBALLY, NO MAJOR COMPROMISE IS
IMMEDIATE. PATIENTS WITH A GCS 8 OR LESS REQUIRE A DEFINITIVE AIRWAY.
• THE PATIENT’S C-SPINE SHOULD BE IMMOBILISED WITH A C-COLLAR
• PERFORM RAPID SEQUENCE INTUBATION
BREATHING AND VENTILATION
• EXPOSE THE NECK AND CHEST, PALPATE AND AUSCULTATE
CIRCULATION WITH HAEMORRHAGE CONTROL
• IV ACCESS (CBC,U&E,RBG, PT,PTT,INR +/-GXM)
• IV CRYSTALLOIDS TO COUNTERACT HYPOVOLEMIA
• CONTROL EXTERNAL HAEMORRHAGE

34. DISABILITY (NEUROLOGICAL EVALUATION)
• GCS
• PUPILLARY SIZE & REACTION
• LATERALIZING SIGNS
EXPOSURE AND ENVIRONMENTAL CONTROL
• VISUAL INSPECTION OF THE ENTIRE BODY
ADJUNCTS
• U-CATH
• OROGASTRIC TUBES

35. INVESTIGATIONS AFTER PRIMARY
SURVEY
• X-RAY AND DIAGNOSTIC STUDIES
• FOCUSED ABDOMINAL SONOGRAPHY TRAUMA (FAST)

36. EVALUATE NEED FOR TRANSFER
CONSULT NEUROSURGERY

37. SECONDARY SURVEY
History
Focused
examination
Adjuncts

38. HISTORY
A
Allergies
M
Medications
currently
used
P
Past illnesses
L
Last meal
E
Events
related to the
injury

39. SECONDARY SURVEY
• INSPECT THE ENTIRE HEAD AND FACE LOOKING FOR:
• LACERATIONS
• CSF LEAK FROM THE EARS AND NOSE
• PALPATE THE ENTIRE HEAD AND FACE LOOKING FOR:
• FRACTURES
• LACERATIONS OVERLYING FRACTURES
• INSPECT ALL SCALP LACERATIONS LOOKING FOR:
• BRAIN TISSUE
• DEPRESSED SKULL FRACTURES
• DEBRIS
• CSF LEAKS

40. SECONDARY SURVEY
• DETERMINE THE GCS SCORE AND PUPILLARY RESPONSE
• EYE-OPENING RESPONSE
• BEST LIMB MOTOR RESPONSE
• VERBAL RESPONSE
• PUPILLARY RESPONSE
• EXAMINE THE CERVICAL SPINE
• PALPLATE FOR TENDERNESS/PAIN AND APPLY A SEMIRIGID C-COLLAR
• PERFORM C-SPINE XRAYS
• DOCUMENT THE EXTENT OF NEUROLOGIC INJURY
• REASSESS THE PATIENT CONTINUOUSLY

41. DEFINITIVE INVESTIGATION

42. ADJUNCTIVE THERAPY
•INTRAVENOUS FLUIDS
•ANTICONVULSANTS
•TETANUS PROPHYLAXIS
•ANTIBIOTIC PROPHYLAXIS
•MANNITOL* OR HYPERTONIC SALINE *(SAH, SDH

43. ADJUNCTIVE THERAPY
• BED ELEVATION (AFTER CLEARING C-SPINE)
• HYPERVENTILATION NOT RECOMMENDED !!!
• MONITOR SERUM GLUCOSE

44. OTHER MANAGEMENT OF NON-
TRAUMATIC BLEED (SAH)
• THE RISK OF REBLEEDING IS GREATEST IN THE FIRST 24 HOURS AND CAN BE
REDUCED BY ADEQUATE BLOOD PRESSURE CONTROL.
• MEAN ARTERIAL PRESSURE OF <130 MM HG IS A REASONABLE TARGET.
• A TITRATABLE IV ANTIHYPERTENSIVE, SUCH AS LABETALOL, IS PREFERRED.
• MONITOR NEUROLOGICAL STATUS

45. RE-EVALUATION

46. TRANSFER TO DEFINITIVE CARE

47. CT SCAN OF MR K
•IDENTIFY THE LESION????

48. REFERENCES
• TINTINALLI EMERGENCY MEDICINE 7TH EDITION
• SECTION 14 CHAPTER 160
• SECTION 21 CHAPTER 254
• ADVANCED TRAUMA LIFE SUPPORT (ATLS) 9TH EDITION STUDENT MANUAL
• CHAPTER 6
• E MEDICINE-MEDSCAPE
• RADIOPAEDIA.ORG

49. THE END