1. Epidural hematoma
a. Middle meningeal artery tear from temporal bone injury.
b. Rapid onset – classic S/S - unresponsive, lucid period, second unresponsiveness.
c. Uncal herniation – ipsilateral pupil dilation, contralateral hemiparesis.
d. Burr holes for emergency treatment since blood above the dura; not appropriate for subdural.
2. Subdural hematoma
a. Tear of the venous bridging veins.
b. Slower decompensation of mental status; hours to weeks.
c. More often in elderly (anticoagulants) and alcoholics from frequent falls.
d. Shaken impact syndrome – triad of SDH, retinal hemorrhage, and posterior rib fractures.
3. Management of increased intracranial pressure (ICP)
a. Hypertonic saline if hemodynamically unstable.
b. Mannitol (osmotic diuretic) 1 gm/kg bolus if hemodynamically stable. Reduces ICP within 1-5 minutes, peaks at 20-60 minutes. Monitor for pulmonary edema initially.
c. Keep SBP > 100 mmHg (110 if older), no permissive hypotension in head injury.
d. Keep CO2 at 35-37, avoid hypoxemia.
e. Elevate HOB to 30-45 degrees, neutral alignment, remove cervical collar.
f. Quiet and dark environment, limit visitors, speak softly, treat anxiety and pain (Fentanyl decreases ICP), no music, treat fever aggressively.
Head Trauma Resources
· Emergency Nurses Association. Trauma Nursing Core Curriculum, 8th ed., 2019.
· Kent, Kendra. Trauma Certified Registered Nurse Examination Review. Springer, 2017.
· Sheehy, S. Sheehy’s Manual of Emergency Care, 7th ed. Elsevier, 2013.