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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Epidural hematoma (EDH) in children: Rapid overview of emergency management

Epidural hematoma (EDH) in children: Rapid overview of emergency management
Clinical features
Head trauma, especially to the temporal or occipital region.
Possible signs and symptoms include:
  • History of loss of consciousness
  • History of altered mental status per caregiver
  • Severe headache
  • Vomiting
  • Lethargy (GCS score 9 to 14) or coma (GCS score ≤8)
  • Irritability, pallor, cephalohematoma (infants ≤12 months), subgaleal hemorrhage
  • Lucid interval for minutes up to several hours followed by clinical deterioration (classic temporal EDH)
  • Ataxia, dizziness with potential for abrupt catastrophic deterioration (posterior fossa EDH)
  • Lateralizing signs (anisocoria, hemiparesis, hemiplegia) and Cushing triad (ie, systolic hypertension, bradycardia, irregular or depressed respiration) are late findings that indicate cerebral herniation
Diagnostic evaluation
The primary goal is to make the diagnosis of EDH before neurologic deterioration in an asymptomatic or mildly affected child to permit timely surgical intervention, if indicated.
Determine GCS score*; perform focused neurologic examination looking for signs of increased ICP or herniation that warrant emergency treatment:
  • Depressed mental status
  • Unequal or abnormal pupil response
  • Asymmetric motor response
  • Decorticate or decerebrate posturing
Stabilize the patient, as needed, and then obtain emergency unenhanced head CT. Most children with EDH also meet criteria for Cspine imaging, (plain radiographs or, in patients with coma or signs of cerebral herniation, CT).
Obtain emergency neurosurgical consultation for all patients with GCS score ≤12 or with EDH on neuroimaging.
Initial laboratory studies:
  • Complete blood count with platelets
  • Coagulation studies (PT, PTT with INR)
  • Type and crossmatch for blood transfusion
  • Other studies may be indicated in multiple-trauma patientsΔ
Lumbar puncture is contraindicated.
Treatment
All children with an acute EDH require emergency neurosurgical consultation. Children with the following clinical findings require emergency surgical hematoma evacuation:
  • Altered mental status (eg, GCS ≤8 or rapidly worsening) due to EDH
  • Signs of increased ICP (eg, persistent vomiting, severe headache, [irritability in infants], or Cushing triad [bradycardia/tachycardia, respiratory disturbance, and hypertension]) due to EDH
  • Signs of cerebral herniation (eg, pupillary abnormalities, focal neurologic findings, or decorticate or decerebrate posturing)
  • Cerebellar signs (patients with occipital injury)
During stabilization, manage the patient according to principles of Advanced Trauma Life Support:Δ
  • Immobilize cervical spine
  • Treat hypoxemia
  • Assess and manage airway, breathing, circulation, and disability
  • Perform endotracheal intubation in children with GCS score ≤8 or rapidly worsening mental status; ventilate to maintain PCO2 between 35 and 40 mmHg
  • Provide fluid resuscitation, as needed, to prevent hypotension
If signs of herniation, provide hyperosmolar therapy (preferably in consultation with a neurosurgeon):◊
  • 3% hypertonic saline solution in a volume of 2 to 6 mL/kg IV per dose (maximum 300 mL), as a rapid bolus infusion. May repeat if needed or initiate infusion. Closely monitor serum sodium concentration and osmolarity (maintain <360 mOsm/L).
  • or
  • Mannitol 20% solution, 0.5 to 1 gram/kg IV per dose, as a rapid bolus infusion. May repeat after 6 hours as needed to increase serum osmolarity (maintain <320 mOsm/L).
Perform mild hyperventilation (PCO2 30 to 35 mmHg) for children whose signs of herniation do not respond to hyperosmolar therapy.

ALT: alanine transferase; AST: aspartate transferase; Cspine: cervical spine; CT: computed tomography; EDH: epidural hematoma; GCS: Glasgow Coma Scale; INR: international normalized ratio; IV: intravenous; PCO2: partial pressure of carbon dioxide; PT: prothrombin time; PTT: partial thromboplastin time.

* Utilize the pediatric GCS when indicated. Refer to UpToDate graphics on the GCS.

¶ Refer to UpToDate topics on evaluation and management of cervical spine injuries in children and adolescents.

Δ Refer to UpToDate topics on trauma in the unstable child.

◊ Refer to UpToDate topics and graphics on the management of increased intracranial pressure in children.
Graphic 69494 Version 10.0

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