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
- Bullock MR, Chesnut R, Ghajar J, et al. Surgical management of acute epidural hematomas. Neurosurgery 2006; 58:S7.
- Besenski N. Traumatic injuries: imaging of head injuries. Eur Radiol 2002; 12:1237.
- Matsumoto K, Akagi K, Abekura M, Tasaki O. Vertex epidural hematoma associated with traumatic arteriovenous fistula of the middle meningeal artery: a case report. Surg Neurol 2001; 55:302.
- Heit JJ, Iv M, Wintermark M. Imaging of Intracranial Hemorrhage. J Stroke 2017; 19:11.
- Roberts I, Yates D, Sandercock P, et al. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 2004; 364:1321.
- Nath F, Galbraith S. The effect of mannitol on cerebral white matter water content. J Neurosurg 1986; 65:41.
- Baekgaard JS, Eskesen TG, Sillesen M, et al. Ketamine as a Rapid Sequence Induction Agent in the Trauma Population: A Systematic Review. Anesth Analg 2019; 128:504.