Management of Epidural Hematoma

Initial Evaluation and Stabilization

The American College of Surgeons recommends immediate intubation of patients with a Glasgow Coma Scale (GCS) ≤8 or signs of neurological deterioration to protect the airway and prevent hypoxia, which causes secondary brain injury 1
Maintaining oxygen saturation >94% is crucial to prevent cerebral hypoxia 1
Avoiding hyperventilation during mechanical ventilation is essential, as it increases mortality in traumatized patients and decreases cardiac output 1
Caution should be exercised when using excessive positive end-expiratory pressure (PEEP) in hypovolemic patients, as it may decrease cardiac output 1
The American Heart Association recommends maintaining systolic blood pressure >100 mmHg to ensure adequate cerebral perfusion 1

Obtaining a non-contrast computed tomography (CT) scan of the head immediately is the gold standard for identifying acute hemorrhage 1
CT angiography can identify active bleeding (contrast extravasation), indicating a high risk of hematoma expansion 1

The American Association of Neurological Surgeons recommends immediate surgical evacuation in patients with neurological deterioration, presence of brainstem compression, cerebellar hematoma volume ≥15 mL, hydrocephalus due to ventricular obstruction, or signs of cerebral herniation 1, 2

Preventing hyperthermia is crucial, as it increases cerebral oxygen demand and worsens secondary brain injury 1
Aggressive treatment of seizures is necessary, as they increase metabolic demand 1
Considering intracranial pressure (ICP) monitoring in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation is recommended 3
Maintaining cerebral perfusion pressure (CPP) between 60-70 mmHg in the absence of multimodal monitoring is essential 4

Reversing warfarin immediately with prothrombin complex concentrate (PCC) or fresh frozen plasma is necessary 1
Using specific reversal agents for new oral anticoagulants (NOACs) when available is recommended 1

Contacting neurosurgery immediately upon diagnosis is crucial 1
The commonly accepted goal is surgery within 4 hours of injury 1
Not delaying transfer to a neurosurgical center is essential, as the lack of critical care beds should never be a reason to reject admission of patients requiring emergency surgery 1