| a.Instruct the client to look up and down without moving his head.8.A nurse is receiving a transfer report for a client who has a head injury. The clienthas a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbalresponse, and 5 for best motor response. Which of the following is anappropriate conclusion based on this data?a.The client opens his eyes when spoken to.9.A nurse in the emergency department is caring for a client who has an epiduralhematoma following a motor-vehicle crash. Which of the following is an expectedfinding for this client?a.Alternating periods of alertness and unconsciousness10.A nurse in the emergency department is caring for a client following anautomobile crash in which the client was unrestrained and thrown from thevehicle. When assessing the client, the nurse observes clear fluid draining fromthe client's nose. Which of the following interventions should the nurse take? What is an epidural hematoma? An epidural hematoma occurs when a mass of blood forms in the space between your skull and the protective covering of your brain. Trauma or other injury to your head can cause your brain to bounce against the inside of your skull. This can tear your brain’s internal lining, tissues, and blood vessels, which results in bleeding. This can cause a hematoma to form. An epidural hematoma can put pressure on your brain and cause it to swell. As it swells, your brain may shift in your skull. Pressure on and damage to your brain’s tissues can affect your vision, speech, mobility, and consciousness. If left untreated, an epidural hematoma can cause lasting brain damage and even death. If you suspect you have an epidural hematoma, get medical attention right away. The symptoms of an epidural hematoma depend on its severity. They can arise minutes or hours after you sustain a head injury. You might have an epidural hematoma if you experience:
You might lose consciousness for a brief period of time. This might be followed by a period of alertness before you fall unconscious again. You can even slip into a coma. An epidural hematoma usually results from trauma or other injury to your head. For example, your brain may be subjected to a damaging blow during a fall, vehicular accident, or collision in contact sports. Physical abuse can also cause head injury and lead to an epidural hematoma. You’re at higher risk of developing an epidural hematoma if you:
If your doctor suspects you have an epidural hematoma, they can use a variety of tests to diagnose and locate it. For example, they may order:
Your recommended treatment plan for an epidural hematoma will depend on the severity of your condition and symptoms. Having other injuries or health conditions can also affect your treatment. SurgeryIn most cases, your doctor will recommend surgery to remove an epidural hematoma. It usually involves a craniotomy. In this procedure, your surgeon will open up part of your skull so they can remove the hematoma and reduce the pressure on your brain. In other cases, your doctor may recommend aspiration. In this procedure, they will cut a small hole in your skull and use suction to remove the hematoma. This may only be effective for a very small hematoma that’s not putting pressure on your brain. MedicationsBefore craniotomy or aspiration, your doctor might prescribe medications to reduce inflammation and intracranial pressure. For example, they may recommend hyperosmotic agents. These drugs can help reduce swelling in your brain. They include mannitol, glycerol, and hypertonic saline. After your hematoma has been removed, your doctor may prescribe antiseizure medications. This can help prevent seizures — a possible complication of head injuries. You might need to take these medications for months or even years. Rehabilitative therapyYour doctor may refer you to a physical therapist, occupational therapist, or other therapist. They can help you manage symptoms and disabilities caused by your injury, such as:
They may recommend exercises to improve your physical abilities, along with other coping strategies. Home careYour recovery process can take time. Most improvements will occur within the first six months after your injury and treatment. Additional improvements may take up to two years. To help promote your recovery process, your doctor will likely encourage you to:
Without prompt medical treatment, an epidural hematoma carries a high risk of death. Even with treatment, it can cause lasting brain damage and disability. Prompt treatment increases your chances of survival and improves your recovery prospects. Following your doctor’s recommended treatment plan can also help you recover, while lowering your risk of complications and permanent disability. It’s not always possible to avoid accidents. As a result, head trauma and epidural hematomas can happen to anyone. But you can lower your risk of injury by taking a few simple safety precautions. For example:
These basic precautions can help protect your head and brain from injury. Extradural hematoma; Extradural hemorrhage; Epidural hemorrhage; EDH An epidural hematoma (EDH) is bleeding between the inside of the skull and the outer covering of the brain (called the dura). An EDH is often caused by a skull fracture during childhood or adolescence. The membrane covering the brain is not as closely attached to the skull as it is in older people and children younger than 2 years. Therefore, this type of bleeding is more common in young people. An EDH can also occur due to rupture of a blood vessel, usually an artery. The blood vessel then bleeds into the space between the dura and the skull. The affected vessels are often torn by skull fractures. The fractures are most often the result of a severe head injury, such as those caused by motorcycle, bicycle, skateboard, snow boarding, or automobile accidents. Rapid bleeding causes a collection of blood (hematoma) that presses on the brain. The pressure inside the head (intracranial pressure, ICP) increases quickly. This pressure may result in more brain injury.
Contact a health care provider for any head injury that results in even a brief loss of consciousness, or if there are any other symptoms after a head injury (even without loss of consciousness). The typical pattern of symptoms that indicate an EDH is a loss of consciousness, followed by alertness, then loss of consciousness again. But this pattern may NOT appear in all people. The most important symptoms of an EDH are: The symptoms usually occur within minutes to hours after a head injury and indicate an emergency situation. Sometimes, bleeding does not start for hours after a head injury. The symptoms of pressure on the brain also do not occur right away.
The brain and nervous system (neurological) examination may show that a specific part of the brain is not working well (for instance, there may be arm weakness on one side). The exam may also show signs of increased ICP, such as:
If there is increased ICP, emergency surgery may be needed to relieve the pressure and prevent further brain injury. A non-contrast head CT scan will confirm the diagnosis of EDH, and will pinpoint the exact location of the hematoma and any associated skull fracture. MRI may be useful to identify small epidural hematomas from subdural ones.
An EDH is an emergency condition. Treatment goals include:
Life support measures may be required. Emergency surgery is often necessary to reduce pressure within the brain. This may include drilling a small hole in the skull to relieve pressure and allow blood to drain outside the skull. Large hematomas or solid blood clots may need to be removed through a larger opening in the skull (craniotomy). Medicines used in addition to surgery will vary according to the type and severity of symptoms and brain damage that occurs. Antiseizure medicines may be used to control or prevent seizures. Some medicines called hyperosmotic agents may be used to reduce brain swelling. For people on blood thinners or with bleeding disorders, treatments to prevent further bleeding might be needed.
An EDH has a high risk of death without prompt surgical intervention. Even with prompt medical attention, a significant risk of death and disability remains.
There is a risk of permanent brain injury, even if EDH is treated. Symptoms (such as seizures) may persist for several months, even after treatment. In time they may become less frequent or disappear. Seizures may begin up to 2 years after the injury. In adults, most recovery occurs in the first 6 months. Usually there is some improvement over 2 years. If there is brain damage, full recovery isn't likely. Other complications include permanent symptoms, such as:
Go to the emergency room or call 911 or the local emergency number if symptoms of EDH occur. Spinal injuries often occur with head injuries. If you must move the person before help arrives, try to keep his or her neck still. Call the provider if these symptoms persist after treatment:
Go to the emergency room or call 911 or the local emergency number if these symptoms develop after treatment:
An EDH may not be preventable once a head injury has occurred. To lessen the risk of head injury, use the right safety equipment (such as hard hats, bicycle or motorcycle helmets, and seat belts). Follow safety precautions at work and in sports and recreation. For example, do not dive into water if the water depth is unknown or if rocks may be present.
National Institute of Neurological Disorders and Stroke website. Traumatic brain injury: hope through research. www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Hope-Through-Research/Traumatic-Brain-Injury-Hope-Through. Updated April 24, 2020. Accessed November 3, 2020. Shahlaie K, Zwienenberg-Lee M, Muizelaar JP. Clinical pathophysiology of traumatic brain injury. In: Winn HR, ed. Youmans and Winn Neurological Surgery. 7th ed. Philadelphia, PA: Elsevier; 2017:chap 346. Wermers JD, Hutchison LH. Trauma. In: Coley BD, ed. Caffey's Pediatric Diagnostic Imaging. 13th ed. Philadelphia, PA: Elsevier; 2019:chap 39.
Last reviewed on: 8/2/2020 Reviewed by: Amit M. Shelat, DO, FACP, FAAN, Attending Neurologist and Assistant Professor of Clinical Neurology, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.
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A nurse is caring for a client who has an epidural hematoma
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