Suddural Hematoma

8/13/2019 Suddural Hematoma

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The curious case ofThe curious case of

Kevin, A cat and SDHKevin, A cat and SDH

Lisa Housel NARLisa Housel NAR

Jake Sareerak NARJake Sareerak NAR

Samuel Merritt UniversitSamuel Merritt Universit

Anatom and !hsiolo"Anatom and !hsiolo"


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#$ o Male %resentin" to %hsician &ith c'o HA ( )

&eek Hit head on %orch &hile searchin" for his cat

Headache *e"an at this time or shortl after HA continue to occur after ar"uments &ith &ife

Sm%toms+ ontinuous HA, all over head and e(tend to

%osterior neck muscles

Ti"ht neck muscles -ision and hearin" are .NL Denies nausea Hasn/t *een slee%in" &ell No relief &ith A!A! and i*u%rofen

ase Stud


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A01(2-S are .NL

Neck is su%%le and 3R1M

Tm%anic mem*rane, o%tic refle(es andretinae are intact

Stead "ait and DTR intact

Dia"nosed &ith muscle tension headache andtreated &ith sedative, muscle rela(ant and%ain medication

all MD if HA does not im%rove over the

&eekend

!hsical 4(amination


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7lood tests


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Referred to neurosur"eon

!erforms craniotom &ith evacuation of

hematoma !er sur"eon, &hen skull %ierced, *lood is

initiall released at a hi"h %ressure

HA minimal after sur"er6 "ood s%irits &ith

famil at *edside

Treatment


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%ir"ay &anagement:

Intubation: Indications for TBI patients:Intubation: Indications for TBI patients:

BRespiratory distress.Respiratory distress.

B&otor posturing'absence of response to pain.&otor posturing'absence of response to pain.

B(ypo)ia'hypercapnia.(ypo)ia'hypercapnia.

B*CS + ,.*CS + ,.

BSei-ures.Sei-ures.

BIncreased ICP.Increased ICP.

Beed for analgesics'sedati$es.eed for analgesics'sedati$es.

BSignificant associated injuries.Significant associated injuries.


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Secondary Brain Injury:

Pathophysiological response to primary neuronal injury

(ours to days after primary insult.

Progressi$e.

(ypo)ia'hypotension are main causes for /

nd

injury.(igh ICP.

(yperthermia.

Brain edema.

(emorrhage .

The primary focus of neurocritical care for TBI is the prevention,identification, and treatment of secondary brain injury.


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Subdural (ematomaTearing of bridging $eins:

Secondary to acceleration'deceleration.

Cresent shaped hematoma.

Hematoma much slower to develop (venous

origin) into a mass large enough to

produce sx

!amage due to impact:

(igher impact than that of E!(.

&ore brain injury and edema.

Treatment:

Symptomatic 0 1 cm thic at its biggest

pointSmaller subdurals may be obser$ed.

&ortality:

Range is 234536.

(igh mortality rate if:

!elay of surgery is 0 7 hrs.


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Cl ifi ti f H d (B i )


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Classification of Head (Brain)Injury

Minimal no loss of consciousness

or amnesia

GCS 15

Mild amnesia or brief (< 5 min)

LC! or im"airedalertness! memory

GCS 1#$15

%ost$concussi&e syndrome

Moderate LC ' 5 min! or focal

neuroloic deficit

GCS $1*

Se&ere

GCS < +

Clas"o& oma Scale7est Motor Res%onse+

1*es# Localies %ain

$ 3le(ion &ithdra&al

9 3le(ion a*normal


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The %eak incidence of SDH is in the #thand Eth

decades of life &hen a lar"er SD s%ace is

availa*le as a result of *rain atro%hThe enlar"ed s%ace accounts for the

%resentin" com%laint of focal sm%tomsrather than those associated &ith increased

5! Sm%toms ma mimic other health %ro*lems+

somnolence, confusion, lethar", andmemor lossF

SDH in 4lderl


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urrent headache is continuous

ommon sm%tom due to the mass effect ofhematoma causin" increase 5! and cere*ral

edema Headache is all over his head, and e(tends into his

%osterior neck muscles, &hich are ti"ht SDH &as *ilateral in ori"in, therefore, no

lateraliation occurred Stiffness of the neck and neck %ain could

additionall *e %resent &hen *lood has *eene(travasated into the su*@arachnoid s%ace

-ision and hearin" are normal and he has no nausea -isual and hearin" deficits &ould *e noted &ith an

5H SDH is located *et&een the dura and arachnoid

s%ace &hich causes %ressure6 venous in natureand usuall slo& *leedF

Si"nificance of

Sm%toms


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A!A! and 5*u%rofen did not relieve headache .HIII

HA related to *lood in su*dural s%ace increasin" 5!

Skull is ri"id, inelastic container that houses the

*rain, *lood volume and S3 Since inelastic container, onl small increases involume &ithin the com%artment can *etolerated *efore %ressure increasesdramaticall


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.hat is the si"nificance of each of the follo&in"

findin"s+ Kevin &as alert 0 oriented, and his vitalsi"ns &ere normal6 his neck &as su%%le and hadnormal ran"e of motion6 his skull &as normal on

%al%ation6 there &ere no si"ns of a*normal cranialnerve function6 his tm%anic mem*ranes &erenormal, as &ere his o%tic refle(es and retinae6 his"ait and dee% tendon refle(es &ere also normalI.hat %ossi*le %ro*lems &ere ruled out in thecourse of this e(aminationI

His sm%toms did not correlate &ith neurolo"icaldeficits that &ould result from a dramatic increasein 5! or herniation

His sm%tom reflect the a*ilit for the intracranialcom%artment to com%ensate for the e(tra *lood *decreasin" S3 %roduction to attem%t to maintainhomeostasis in relation to %ressure

Results of !hsical4(am


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7lood collected in the su*dural s%ace dra&s

&ater due to osmosis

3urther com%ressin" *rain tissueausin" ne& *leeds * tearin" other *lood

vessels

!atho%hsiolo"


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5ncreased thro**in" %ain


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.hIIIIII

H17 )$ to 9$ de"ree 5!

H17 9$ de"ree !!H17 flat 5! 8 More headache and %ain

!ositionin"@@H17 elevated &ith head midlineto avoid im%edin" venous return

5ncreased thro**in" %ain&hen lin" do&nI


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De%ends on the sie of the hematoma and the

de"ree of an associated %arenchmal *rain

inGur headache, nausea, confusion, %ersonalit chan"e,

decreased level of consciousness, s%eechdifficulties, other chan"e in mental status,

im%aired vision or dou*le vision, and &eaknessA dilated or nonreactive %u%il i%silateral to the

hematoma


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7ilateral fi(ed and dilated %u%ils are secondar toinadeuate cere*ral %erfusion

ere*ral h%o(ia and severe increased 5!

!u%ils that are fi(ed and dilated

5rreversi*le inGur

A unilateral fi(ed


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A findin" of si"nificant asmmetr durin" the

motor e(amination ma *e indicative of a

hemis%heric inGur and raises the %ossi*ilitof a mass lesionF

Mid*rain controls ocular motion

!ons coordination of ee and facialmovement

Hearin" and *alance

7alance and Cait


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Signs of Cerebral (erniation

8nconscious'unresponsi$e Patient8nconscious'unresponsi$e Patient

%symmetric pupils.%symmetric pupils.

!ilated or fi)ed pupil9s: unilaterally or bilaterally.!ilated or fi)ed pupil9s: unilaterally or bilaterally.

8nresponsi$e to painful stimuli.8nresponsi$e to painful stimuli.

Patient displays posturing.Patient displays posturing.

;irst abnormal fle)ion:;irst abnormal fle)ion: decorticatedecorticate..

Then abnormal e)tension:Then abnormal e)tension: deceberatedeceberate..

Cushing


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.hat does this indicatesI

Hi"h 5!

Hi"h 1%enin"

!ressure


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Suddural Hematoma