Overview
This lecture covers the emergency management of a traumatic brain injury patient with an acute subdural hematoma, focusing on diagnostic steps, surgical intervention, and relevant guidelines.
Initial Patient Assessment
- Patient struck by a car, presenting agitated with declining Glasgow Coma Scale (GCS) from 13 to 6.
- Notable findings: right pupil larger than left, withdrawal/flexion from pain, open tib-fib fracture.
- Vital signs: heart rate 70, blood pressure 180/98.
- Focused Assessment with Sonography for Trauma (FAST) scan negative for free fluid.
- Patient is intubated for airway protection.
Imaging and Diagnosis
- Always obtain a CT head in a hospital setting before invasive procedures, even with signs like a blown pupil.
- CT head shows large right-sided acute subdural hematoma with significant midline shift.
- False localization can occur; imaging clarifies diagnosis before intervention.
Surgical Management
- Acute subdural hematomas >1 cm thick with >5 mm midline shift, or rapid GCS decline, require urgent surgical evacuation.
- Large craniotomy preferred over small to adequately remove gelatinous clot.
- Positioning: supine with head turned; no pinning necessary for trauma craniotomies.
- After hematoma evacuation, assess brain swelling to decide whether to replace the bone flap.
- Consider placement of external ventricular drain (EVD) to monitor or relieve intracranial pressure.
External Ventricular Drain (EVD) Placement
- EVD can be placed intraoperatively or afterward if brain appears swollen.
- Typical insertion point is "Kocher’s point"; avoid Broca’s area on the left to prevent speech deficits.
Key Terms & Definitions
- GCS (Glasgow Coma Scale) — a scale to assess consciousness in trauma patients.
- Subdural Hematoma — a collection of blood between the brain surface and dura mater, often due to trauma.
- Midline Shift — displacement of brain structures due to mass effect from bleeding or swelling.
- FAST scan — bedside ultrasound to detect internal bleeding.
- Craniotomy — surgical opening of the skull to access the brain.
- EVD (External Ventricular Drain) — a device to drain cerebrospinal fluid and monitor intracranial pressure.
Action Items / Next Steps
- Review Brain Trauma Foundation guidelines for acute subdural hematoma management.
- Understand criteria for surgical evacuation based on CT findings and patient status.
- Practice identification of proper EVD insertion points and craniotomy techniques.