24 year old male presents to the ER after getting hit on the head by a baseball going approx. 80mph. He was not wearing a helmet at the time. He passed out for about 20 seconds but quickly returned back to baseline and now acting normally, just complaining of a small headache.
Epidural hematoma occurs from the tearing of the middle meningeal artery resulting in blood collecting between the skull and the dura mater in the epidural space. They are generally associated with blunt trauma to the temporal region with a high incidence of associated skull fracture.
Presentation: lucid interval is the classic teaching for patients with an epidural hematoma, where there’s a temporary improvement in patient’s condition before rapid deterioration. That’s why it’s important to observe these patients in the ER even if the suspicion is low to prevent catastrophic outcomes.
Workup: anyone who presents with a severe mechanism will warrant a non-contrast head CT. High risk patients are those with neurologic deficits, abnormal GCS score, or palpable skull fracture. Classic CT finding will reveal a lens shaped or biconvex hyperdense (white) lesion with sharp margins near the temporoparietal region, not crossing suture lines.
Management: early Neurosurgery consult for possible rapid decompression. While in the ER, it’s important to quickly manage increased intracranial pressure (ICP) and maintaining cerebral perfusion. Strategies include elevation of head of bed at 30deg, fluid resuscitation, hyperventilation, mannitol or hypertonic saline.
Epidural hematoma is no joke and something we do not want to miss. Watch out for lucid intervals as the patient’s normal mentation might trick you. Happy Hump Day! How’s everyone’s week going? Who’s counting down to the weekend?
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