Describe the pathophysiology of extradural and subdural hematomas. Identify the surgical emergency and provided rationale for the choice.

Patient 1 – Two individuals come to the emergency department with head injuries. One, 25 years old, has just been in a motor vehicle accident (MVA) and has a temporal lobe injury. The severity of traumatic brain injury is a well-established risk factor for post-traumatic epilepsy.

The other, 65 years old, has increasing confusion after a fall that happened earlier in the week.

Both of these patients need a thorough review of their medical record with a detailed history and physical with an in depth neurological assessment, we would also need to assess the condition of the accident and whether seat belts were worn or if there head hit anything in the car [ CITATION Hed19 l 1033 ]. The patient’s need frequent vital signs and Glasgow Coma Scores, Simplified Acute Physiology Score to be calculated within twenty-four hours after initial admission [ CITATION Hed19 l 1033 ]. These will monitor motor deficits, pupil responses, convulsions, presence of any shock or arterial hypotension that can lead to cardiac arrest [ CITATION Hed19 l 1033 ]. They will need a CT scan of the brain, CT of the neck to find possible presence of hematomas possibly extradural, subdural, or intracerebral [ CITATION Hed19 l 1033 ]. The CT can also identify cerebral edema, subarachnoid hemorrhage, cerebral contusion pneumocephalus, or intracranial mass lesion or a midline shift [ CITATION Hed19 l 1033 ]. with serum glucose, sodium levels, blood urea, urine specific gravity, arterial blood gases, CBC to monitor blood concentration, platelet count, and prothrombinaemia. Age shows evidence to influence the prognostic factor of how a traumatic brain injury will affect a person with mortality being higher with patients older than 38 years old [ CITATION Hed19 l 1033 ].

Differentiate the pathophysiology of extradural hematoma and subdural hematoma. An extradural hematoma (EDH), also called an epidural hematoma, is a collection of blood that has formed between the inner surface of the skull and outer layer of the dura also known as the endosteal layer of the brain [ CITATION Ary19 l 1033 ]. These hematomas are usually the result of head trauma and skull fractures [ CITATION Ary19 l 1033 ]. Most of the time the bleeding source of these injuries is arterial usually from a torn middle meningeal artery [ CITATION Ary19 l 1033 ]. They are able to be seen in CTs and MRIs and if treated promptly the prognosis is generally good [ CITATION Ary19 l 1033 ].

A subdural hematoma is also a collection of blood that occurs between the dura and the surface of the brain [ CITATION Med201 l 1033 ]. These are usually caused by severe head trauma or injuries [ CITATION Med201 l 1033 ]. The bleeding from a subdural hematoma fills the brain very quickly, compressing the brain tissue which results in death [ CITATION Med201 l 1033 ]. These particular injuries can occur with just a minor injury where the bleeding occurs slowly and go unnoticed for days or weeks [ CITATION Med201 l 1033 ].

Identify the patient in the above scenario requiring immediate emergency surgical intervention and provide rationale for your choice. The 65-year-old patient is currently displaying the possibility of a subdural hematoma and requires immediate intervention to either prove it or disprove the bleed [ CITATION Hea17 l 1033 ]. If he has a subdural hematoma, he is at a high risk for death due to his age and the atrophy that puts him at a higher risk for death [ CITATION Hea17 l 1033 ]. Bleeding from a subdural hematoma in the elderly leads to a higher mortality rate [ CITATION Hea17 l 1033 ].

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Post-Traumatic Epilepsy has been defined as the development of unprovoked seizures in a delayed fashion after traumatic brain injury (TBI) [ CITATION Hea17 l 1033 ].

Patient 2 – A 38-year-old was driving his 1970 Chevy Corvette to a Milwaukee Brewers baseball game when a deer jumped out in front of him on the highway. He swerved his car and hit a telephone pole instead. His head hit the windshield and he suffered severe head trauma.

a. Describe the most likely specific type of head injury he suffered. Extradural Hematoma

b. Outline the treatment plan for this patient.

Treatment plan:

1. Assess neurologic and respiratory status to monitor for the sign of increased ICP (Increased intracranial pressure) and respiratory distress[ CITATION Mar19 l 1033 ].

2. Must monitor and record major symptoms and intake and output, increased intracranial pressure, hemodynamic variables, cerebral perfusion pressure, specific gravity, laboratory studies and pulse oximetry to detect early sign of compromise [ CITATION Mar19 l 1033 ].

3. Observe for the sign of increasing increased intracranial pressure (ICP) to avoid treatment delay and prevent neurologic compromise [ CITATION Mar19 l 1033 ].

4. Assess for CSF leak as evidenced by otorrhea or rhinorrhea. Cerebrospinal fluid (CSF) leak could leave the patient at risk for infection [ CITATION Mar19 l 1033 ].

5. Assess for pain. Pain may cause anxiety and increase increased cranial pressure [ CITATION Mar19 l 1033 ].

6. Check a cough and gag reflex to prevent aspiration [ CITATION Mar19 l 1033 ].

7. Must check for different symptoms of diabetes insipidus (High urine output, low urine specific gravity) to maintain hydration [ CITATION Mar19 l 1033 ].

8. Administer I.V fluids to maintain hydration [ CITATION Mar19 l 1033 ].

9. Administer oxygen to maintain position and patency of endotracheal tube if present, to maintain the airway and hyperventilate the patient and to lower increased intracranial pressure (ICP) [ CITATION Mar19 l 1033 ].

10. Provide suctioning; if the patient is able, assist with turning, coughing and deep breathing to prevent pooling of secretions [ CITATION Mar19 l 1033 ].

11. Maintain position, patency, and low suction of NGT to prevent vomiting [ CITATION Mar19 l 1033 ].

12. Maintain seizure precautions to maintain patient safety [ CITATION Mar19 l 1033 ].

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13. Administer medication as a prescription to decrease increased intracranial pressure (ICP) and pain [ CITATION Mar19 l 1033 ].

14. Allow a rest period between nursing activities to avoid the increase in increased intracranial pressure (ICP) [ CITATION Mar19 l 1033 ].

15. Encourage the patient to express feeling about changes in body image to allay anxiety [ CITATION Mar19 l 1033 ].

16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awareness of the environment [ CITATION Mar19 l 1033 ].

17. Provide means of communication, such as a communication board to prevent anxiety [ CITATION Mar19 l 1033 ].

18. To prevent tissue damage, provide eye, skin, and mouth care [ CITATION Mar19 l 1033 ].

19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown [ CITATION Mar19 l 1033 ]

References Chelly, H., Bahloul, M., Ammar, R., Dhouib, A., Mahfoudh, K. B., Boudawar, M., . . . Boaaziz, M. (2019).

Clinical characteristics and prognosis of traumatic head injury following road traffic accidents

admitted in ICU. European Journal of Trauma and Emergency Surgery, 245-253.

Health & Medicine Week. (2017, January 13). Central Nervous System Diseases and Conditons-Post-

Traumatic Epilepsy; Findings from Case Western Reserve University Provide New Insights into

Post-Traumatic Epilepsy. Atlanta: ProQuest.

Kabbani, A., & Gallard, F. (2019, May 15). Extradural hemorrhage. Retrieved from radiopaedia.org:

https://radiopaedia.org/articles/extradural-haemorrhage?lang=us

Medline Plus. (2020, August 12). Medical Encyclopedia. Retrieved from Medline Plus:

https://medlineplus.gov/ency/article/000713.htm

Mona, M. (2019, March 6). Nursing Interventions of Head Injury Patients.

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