Epidural hematoma (ie, accumulation of blood in the potential space between dura and bone) may be intracranial (EDH)

or spinal (SEDH) (see the image below). Intracranial epidural hematoma occurs in approximately 2% of patients with head injuries and 5-15% of patients with fatal head injuries. Intracranial epidural hematoma is considered to be the most serious complication of head injury, requiring immediate diagnosis and surgical intervention. Intracranial epidural hematoma may be acute (58%), subacute (31%), or chronic (11%). Spinal epidural hematoma may also be traumatic, though it may occur spontaneously.

This MRI demonstrates spinal epidural hematoma. Pathophysiology Epidural hematoma usually results from a brief linear contact force to the calvaria that causes separation of the periosteal dura from bone and disruption of interposed vessels due to shearing stress. Skull fractures occur in 8595% of adult cases, but they are much less common in children because of the plasticity of the immature calvaria. Arterial or venous structures may be compromised, causing rapid expansion of the hematoma; however, chronic or delayed manifestations may occur when venous sources are involved. Extension of the hematoma usually is limited by suture lines owing to the tight attachment of the dura at these locations. Recent analyses have revealed that epidural hematomas may actually traverse suture lines in a minority of cases.[1] The temporoparietal region and the middle meningeal artery are involved most commonly (66%), although the anterior ethmoidal artery may be involved in frontal injuries, the transverse or sigmoid sinus in occipital injuries, and the superior sagittal sinus in trauma to the vertex. Bilateral epidural hematomas account for 2-10% of all acute epidural hematomas in adults but are exceedingly rare in children. Posterior fossa epidural hematomas represent 5% of all cases of epidural hematomas. Spinal epidural hematoma may be spontaneous or may follow minor trauma, such as lumbar puncture or epidural anesthesia. Spontaneous spinal epidural hematoma may be associated with anticoagulation, thrombolysis, blood dyscrasias, coagulopathies, thrombocytopenia, neoplasms, or vascular malformations. The peridural venous plexus usually is involved, though arterial sources of hemorrhage also occur. The dorsal aspect of the thoracic or lumbar region is involved most commonly, with expansion limited to a few vertebral levels. Epidemiology Frequency United States Epidural hematoma complicates 2% of cases of head trauma (approximately 40,000 cases per year). Spinal epidural hematoma affects 1 per 1,000,000 people annually. Alcohol and other forms of intoxication have been associated with a higher incidence of epidural hematoma. International International frequency is unknown, though it is likely to parallel the frequency in the United States. Mortality/Morbidity Mortality rate associated with epidural hematoma has been estimated to be 5-50%. The level of consciousness prior to surgery has been correlated with mortality rate: 0% for awake patients, 9% for obtunded patients, and 20% for comatose patients. y Bilateral intracranial epidural hematoma has a mortality rate of 15-20%. y Posterior fossa epidural hematoma has a mortality rate of 26%. Race

No racial predilection has been reported. Sex Intracranial and spinal epidural hematomas are more frequent in men, with a male-to-female ratio of 4:1. Age

y y y

Intracranial epidural hematoma is rare in individuals younger than 2 years. Intracranial epidural hematoma is also rare in individuals older than 60 years because the dura is tightly adherent to the calvaria. Spinal epidural hematoma has a bimodal distribution with peaks during childhood and during the fifth and sixth decades of life. Increasing age has been noted as a risk factor for postoperative spinal epidural hematoma.

Head Injury Symptoms: When to Seek Medical Care

There are a variety of types of head injuries, and the outcomes vary greatly. One type of brain injury is an epidural hematoma. The acclaimed actress Natasha Richardson suffered this type of hematoma after falling while skiing in Canada in 2009. Unfortunately, despite all of the emergency care Ms. Richardson's received, she did not survive. An epidural hematoma occurs when there is bleeding between the dura mater (a tough fibrous layer of tissue between the brain and skull) and the skull bone. These occur when arteries are torn as a result of a blow to the head, and injury in the temple area is a common cause. Although the pattern of a lucid interval followed by later neurological symptoms is characteristic, only a minority of patients display this pattern of symptoms. Reported death rates from epidural hematoma vary widely, ranging from 5% to over 40%, depending upon the patient population under study. To begin understand how something like this can happen, let's review the serious topic of minor head trauma and the potential that it has to become major head trauma. Minor head injuries are defined as those where trauma causes a temporary loss of mental function, however, there is still a potential risk that something bad might happen. In fact, there are numerous guidelines to help physicians decide who might need a CT scan to look for brain bleeding or injury. The February 2009 edition of the Annals of Emergency Medicine contained an article that compared six different sets of guidelines. The conclusion was that each worked equally well in predicting who may or may not have bleeding in the brain. If the symptoms were not present, then it was safe to reassure the patient and family and let them go home. If symptoms were there, a CT scan was needed to look for brain damage. Often, the injury that causes brain damage may not be dramatic or very traumatic, and the person may not initially lose consciousness. But for those few, where the head is hit in just the right place with just the right amount of force, the potential for swelling in the brain is real. The New Orleans Criteria found seven symptoms that suggest when to obtain a CT scan. These same seven symptoms are reasonable as a guide to seek medical attention after a head injury: 1. Headache 2. Vomiting 3. Short term memory loss 4. Alcohol intoxication 5. Seizure 6. Physical evidence of trauma to the head or neck 7. Age over 60 Other guidelines would add dangerous mechanism of injury such as being hit by a car or falling down steps, and being on a blood thinner like warfarin(Coumadin) or clopidogrel bisulfate (Plavix). Head injuries are all too common, with almost 250,000 admissions to hospitals in the US each year and an estimated 50,000 deaths. Car wrecks and sports injuries account for up to 90% of these injuries. Kids aren't immune - head injuries cause over 2,500 deaths each year in children under the age of 14.

It is difficult for the patient to know when to seek care because of confusion or amnesia as to the events surrounding the injury along with a lack of objectivity. That objectivity is tough even for parents or family members, and the decision to seek medical care is sometimes difficult to make. A guiding principle might be, regardless of age, if the injured patient isn't acting like themselves, then medical care is needed. And all bets are off if alcohol or other drugs are involved; medical care should be sought immediately. The best outcomes for head trauma occur when the injured patient arrives at the health care facility while they are still awake. Coma or unconsciousness is not a good sign. But even if everything is done right, the brain does not like being injured and may take a long time to return to normal function and potentially may not return to "normal." Accidents and injuries happen in life, and even with the most prompt and appropriate care, there is no guarantee for a perfect outcome.

Kimberly Ann U. Caberte Mr. Rey D. Pinalba, RN,MN

Specific Objectives
At the end of 2 days duty, I will be able to explore and improve nurses role to meet the needs of my patient. And I will be able to take my time wisely and manageably: Achieving good results by having effective nursing interventions. Client centered approach should be implemented Avoid places for mistakes Maintain poise and patience, appropriate behavior during duty.

y y y y

Kimberly Ann U. Caberte Mr. Rey D. Pinalba,RN,MN

Daily Plan of Activities

6:45 7:00 Pre Conference 7:00 - 7:30 7:30 - 8:00 8:00 - 8:30 8:30 - 9:00 9:00 - 9:30 Vital Signs Taking Drug Recital Giving Meds Make a Tentative Nurses Notes Go to the Patient Bed side

9:30 - 11:30 Break Time!!! 11:30 - 12:00 Vital Signs Taking 12:00 - 1:30 Giving Meds/ Patients Monitoring 1:30 2:00 Charting 2:00 2:30 Intake and Output Measured 2:30 3:00 Post Conference