Epidural Hematoma

epidural hematoma

Authors: Kilalo Maeli Mjema, Emergency Physician and Mugisha Clement, Neurosurgeon.

Case Presentation

A 34 years old male sustained a traumatic brain injury following a motor vehicle accident 3 hours before presentation to ED. BP: 117/69mmHg. HR: 84, RR: 18, SPO2: 99% in room air, T: 36.9.

Primary Survey

Airway: patent and protected
Breathing: bilateral equal air entry
Circulation: warm extremities, 1 second capillary refill time
Disability: alert and oriented, pupils 4mm bilaterally equally reactive to light, RBG 5.6 mmol/L
Exposure: raccoon right eye, bruises on the forehead and upper limbs

SAMPLE History

Signs and symptoms: mostly chest pain than the headache, nausea
Allergies: no known allergies
Medication: had received tramadol, dexamethasone, tetanus toxoid and some intravenous fluids before being referred to our facility
Past medical history: no known comorbid or any significant history
Event: sustained motor vehicle accident as a motorcycle driver with no helmet on 3 hours prior presentation, associated with a 20 minutes loss of consciousness. Attended at another facility where he regained his full consciousness, wounds dressed, medication given as above, E-FAST negative and CT imaging done. He remained conscious throughout and was transferred for neurosurgical observation and interventions.

Neuro-observation and continuous monitoring were planned. Blood samples sent for CBC, PT, aPTT, blood type and crossmatch. The neurosurgical review was done, and the patient was to be kept inpatient for close neurosurgical observation and interventions as needed.

Patient progress while still in the ED

In the course of stay in the ED, the patient started to vomit, became drowsier overtime, was moving mostly the right side of his limbs. The right pupil was 6-7mm non-reactive to light and GCS dropped to E1M4(Rt)V2

Vitals

BP 133/79 mmHg HR 39-45 bpm RR 14 rpm SPO2 99% in room air.

The patient was emergently transferred for repeat imaging and prepared for emergency craniotomy and hematoma evacuation. Theatre was informed and ready to receive the patient.

Rapid sequence induction and intubation 

  • Patient pre-oxygenated
  • Induction with iv ketamine 2mg/kg (weight 75kg)
  • Paralyzed with iv suxamethonium 100mg 
  • Intubated by sized 8 cuffed ETT

Mannitol 20g iv infusion was given over 10 minutes.

Intraoperative Findings and Progress

Right frontotemporoparietal craniotomy was done. Approximately 100 mls of hematoma because of spurting bleeding from the medial meningeal artery was found.  No other obvious identifiable bleeding was seen. Hemostasis was achieved and closed in layers with a drain. The patient had a complete neuro improvement, extubated at day 5 and discharged 9th day.

Clinical Pearls

  • The incidence of epidural hematoma is highest among adolescents and young adults
  • Most cases are a result of head trauma by traffic accidents, falls or assaults
  • Most commonly due to middle meningeal arterial bleed
  • Epidural hematoma does not cross suture margins but crosses dural attachments as a convex lens shaped appearance
  • Lucid intervals are seen in patients
  • Watch for raised intracranial pressure; ipsilateral dilated pupil, Cushing reflex, altered mentation, vomiting
  • Glucocorticoids have no role in reducing cerebral edema in traumatic brain injury
  • In the presence of epidural hematoma with the feature of herniation, mannitol can be given with caution that craniotomy and evacuation is going to be done immediately
  • Ketamine in RSII can still be considered in traumatic brain injury where blood pressures are not raised

Clinical Pearls

In the context of non-operative management, properly monitoring neurologic status and progress is the key factor to recognise early need of emergency medical intervention, re-imaging and neurosurgery.   

References and Further Reading

Cite this article as: Kilalo Mjema, "Epidural Hematoma," in International Emergency Medicine Education Project, January 15, 2020, https://iem-student.org/2020/01/15/epidural-hematoma-2/, date accessed: January 17, 2022

ELECTRIC SHOCK; Injuries beyond what the eyes see.​

electric shock

Authors: Dr. Nour Saleh and Dr. Kilalo Mjema

Case presentation

A 53-years-old male, sustained burn wounds on both hands 40 minutes prior presentation to the ED

Primary survey

  • Airway: patent and protected.
  • Breathing: bilateral equal air entry
  • Circulation: warm extremities, capillary refill time is 1 second
    • Vitals on presentation
      • BP: 177/114mmHg
      • HR: 115
      • RR: 16
      • SPO2: 96% in room air
      • T: 36.4
  • Disability: alert and oriented, pupils 5mm bilateral equal light reaction, glucose: 7.3mmol
  • Exposure: holding his hands up in pain with some black discoloration

SAMPLE History

  • Sign and symptoms: pain, see pictures
  • Allergy: no known allergies
  • Medications: not on any medication
  • Past medical history: no known comorbid or any significant medical history
    Last meal: he ate about 2.5 hours prior presentation
  • Event: pain on both hands after sustaining burn injury forty minutes prior presentation to the ED while trying to connect two circuits that sparked causing burn wounds on his hands and felt a jolt of electricity.

No history of heartbeat awareness or any loss of consciousness

electrical injury
electrical injury

Interventions and key steps in management

  • Make sure ABCD is checked and there is no critical intervention needed
  • IV access and fluid resuscitation may be considered depending on the case
  • Analgesics: depends on the severity of pain. Fentanyl 50mcg IV stat can be necessary for many patients.
  • Informed consent for procedural sedation for the dressing of the wounds.
  • Sedation: during the dressing of wounds
  • Point-of-care investigations: ECG, Urine dipstick
  • Blood samples for some labs should be taken; Creatinine, CK, Myoglobin, Electrolytes, Calcium, and Troponin
  • Imaging: X-ray if there is a worry for associated fracture
  • Monitor: input of fluids and output of urine to watch for acute kidney injury, compartment syndrome and rhabdomyolysis
  • Do not forget tetanus immunization

Associated injuries

  • Cardiac arrhythmias

    Ventricular fibrillation is the most common. It occurs in 60% of patients with electrical current traveling from one hand to the other.

  • Renal - Rhabdomyolysis

    Massive tissue necrosis may result in acute kidney injury. Labs to check includes; Creatinine, Blood Urea Nitrogen, Total CK, myoglobin.

  • Neurological

    Damage to both central and peripheral nervous systems can occur. The presentation may include weakness or paralysis, respiratory depression, autonomic dysfunction, memory disturbances, loss of consciousness.

  • Skin

    Degree of injury cannot determine the extent of internal damage especially with low voltage injuries. Minor surface burns may co-exist with massive muscle coagulation and necrosis.

  • Musculoskeletal

    Bones have the highest resistance of any body tissues resulting in the greatest amount of heat when exposed to an electrical current. Results in surrounding tissue damage and potentially may lead to periosteal burns, destruction of bone matrix and osteonecrosis.

  • Vascular / Coagulation system

    Due to electrical coagulation of small blood vessels or acute compartment syndrome.

  • Internal organs

    The internal organ injury is not common but when it happens may result serious problems such as bowel perforations leading to polymicrobial infection, sepsis, and death.

Disposition

Admission and discharge decisions of burn patients depend on the patient’s current situation, burn percentage according to body surface area, location of the burn, and complications of burn. Low voltage electrocutions, if they are asymptomatic with normal physical examinations, can be discharged. Discharge precautions regarding burn care and complications should be clearly explained to the patient and relatives.

Further Reading

Cite this article as: Kilalo Mjema, "ELECTRIC SHOCK; Injuries beyond what the eyes see.​," in International Emergency Medicine Education Project, October 2, 2019, https://iem-student.org/2019/10/02/electric-shock-injuries-beyond-what-the-eyes-see-%e2%80%8b/, date accessed: January 17, 2022

A becoming specialty – EM in Tanzania

We all pass through milestones of growth and every stage is a hurdle to the next, how we choose to view it is our own choosing. Imagine seeing it from a child’s perspective; a five-month-old wobbly reaching for a shiny new toy that seems just a grasp away, falls flat on his face cries then realises; ooh wait there is that shiny new toy again. Picks up from where he left off and with every advance sitting transforms to crawling.

Joshua Yonazi 2014
Currently doing her Paediatric Cardiology Fellowship

As a medical student, I had no exposure to Emergency Medicine as a specialty. We had an OPD that was functional 24 hours. Paediatrics was what I set my mind to do, and Dr. Stella Mongella, who remains a role model to date influenced a lot of what I am today in my timeliness and responsibilities. It was a see admire and try to become not her but myself in the best way I could. 

After completing my medical school, which is a five-year program, the next step was to go for my one-year internship training. I moved from a mostly public health facility to a private health facility. It was until 2014 when I was employed as a Resident Medical Officer at the Accidents and Emergency Department of the Aga Khan Hospital Dar es Salaam when I met Dr. Yash Dubal, an Emergency Physician who had just joined the hospital that same year. He had graduated from Muhimbili University of Health and Allied Sciences (MUHAS) and working with him is what made me realise what a becoming speciality Emergency Medicine is and in less than a year I decided to join the same residency program he had graduated from.

This three-year residency program is a core competency-based training in research, trauma, paediatric care, leadership skills, bedside ultrasound, recognition and treatment of toxicological, obstetric and medical emergencies. Offers elective exchange opportunities for residents to go abroad for observership as well as those from abroad coming to Tanzania. Muhimbili National Hospital first and the only hospital to date to have an Emergency Medicine Residency Program in Tanzania and first to have initiated an Undergraduate Emergency Medicine Rotation in 2014. Since the presence of this fully capacitated Emergency Medicine department, there has been great change in the delivery of services and outcome within the hospital and its graduates are part of regionalisation of emergency care in Tanzania.

To date there are nine health facilities with fully functional 24 hours emergency departments with Emergency Physicians available at; Muhimbili National Hospital, Bugando Medical Center, Kilimanjaro Christian Medical Center, Arusha Lutheran Medical Center, Mount Meru Hospital, Mbeya Zonal Referral Hospital, Bombo Hospital, Benjamin Mkapa Hospital and The Aga Khan Hospital. Development of EMS is in progress with basic ambulance providers, attendants and dispatch training complete.

Muhimbili National Hospital
Mbeya Zonal Referral Hospital
Benjamin Mkapa Hospital
Kilimanjaro Christian Medical Center
Emergency Medical Services
The Aga Khan Hospital Dar es salaam

Emergency Medicine is a Becoming Specialty with core values to safely deliver those critically ill and injured from the community to the acute care units for resuscitation, stabilization and transfer to specific units for definitive care.

Cite this article as: Kilalo Mjema, "A becoming specialty – EM in Tanzania," in International Emergency Medicine Education Project, June 24, 2019, https://iem-student.org/2019/06/24/a-becoming-specialty-em-in-tanzania/, date accessed: January 17, 2022