Acute SDH Seminar Presentation by Rebira W..pptx

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1. Institute of Health Science Department of Nursing Postgraduate Program of Adult Health Nursing Subdural Hematoma Seminar Presentation Set By: Rebira Workineh (AHN Student) Rebira W. ( AHN student) 13 December 2023 1

2. Table of Contents 13 December 2023 Rebira W. ( AHN student) 2 Introduction Epidemiology Types of SDH Pathophysiology Etiology Clinical manifestations Investigations Differential diagnosis Medical management Nursing care plan Complication Prevention Prognosis References

3. Introduction 13 December 2023 Rebira W. ( AHN student) 3 Definition A SDH is a collection of blood that forms in the subdural space, the space between the dura mater and the arachnoid mater but external to the brain and arachnoid membrane. It is the most common type of traumatic intracranial mass lesion The brain has three membrane layers called meninges that lie between the bony skull & the brain tissue

4. 13 December 2023 Rebira W. ( AHN student) 4

5. Introduction Cont’d… 13 December 2023 Rebira W. ( AHN student) 5 A client with SDH may be experienced a tear in a blood vessel, most commonly in a vein & blood is leaking out of the torn vessel into the space below the dura mater membrane layer Bleeding into this space is called a subdural hemorrhage, other names of SDH Subdural hemorrhage Intracranial hematoma More broadly, it is also a type of traumatic brain injury (Pierre L, et al, 2021)

6. Epidemiology 13 December 2023 Rebira W. ( AHN student) 6 A study revealed that acute SDH have been reported to occur in 5-25% of patients with severe head injury The annual incidence of chronic SDH has been reported to be 1-5.3 cases per 100,000 population Acute SDHs are more common in men than in women with a M-F ratio of 3:1 Chronic SDH has also a higher incidence in men than women with M-F ratio of 2:1 The incidence of chronic SDH appears to be highest in the 50 th through 70 th of life

7. Reasons For Variation 13 December 2023 Rebira W. ( AHN student) 7 Cranial size: Contribute to pathogenesis or risk factor Great exposure of males to injury Men sustain nearly 2 to 3 times as many brain injury as women Estrogen effect on the capillaries Increase the level of procoagulation factors, reduce anticoagulant factors Fewer medical visit of females (Jae-sang Oh, et al, 2014)

8. Types of SDH 13 December 2023 Rebira W. ( AHN student) 8 SDH may be: Hyperacute SDH- Within 24 hours Acute SDH- Within 48-72 hours Sub-acute SDH- Within 3-21 days Chronic SDH- Within 3 wks. to months

9. Types Cont’d… 13 December 2023 Rebira W. ( AHN student) 9 Acute SDH is commonly associated with extensive primary brain injury. A study revealed that 82% of comatose patients with acute SDH had parenchymal contusions. Acute SDH is the most common type of traumatic intracranial hematoma, occurring in 24% of patients who present comatose. (Kotwica Z, et al, 1993)

10. Pathophysiology 13 December 2023 Rebira W. ( AHN student) Bleeding in a SDH occurs from tearing of the bridging veins that cross from the cortex to the dural venous sinuses, which are vulnerable to deceleration injury This subsequently leads to accumulation of blood between the dura and arachnoid and results in a gradual rise in intracranial pressure This can lead to herniation and brainstem death if left untreated

11. Etiology 13 December 2023 Rebira W. ( AHN student) 11 Head trauma Coagulopathy Medical anticoagulation (e.g., warfarin, heparin) Hemophilia Liver disease Thrombocytopenia

12. Etiology Cont’d… 13 December 2023 Rebira W. ( AHN student) 12 Non-traumatic intracranial hemorrhage Hypertension (most common) Cerebral aneurysm Arterio-venous malformation Tumor (meningioma or dural metastases) Postsurgical Craniotomy CSF shunting

13. Etiology Cont’d… 13 December 2023 Rebira W. ( AHN student) 13 Intracranial hypotension After lumbar puncture Lumbar CSF leak Lumbo-peritoneal shunt Spinal epidural anesthesia Shaken baby syndrome Spontaneous or unknown-rare ( Mashour GA, et al, 2006 )

14. Clinical Manifestations 13 December 2023 Rebira W. ( AHN student) 14 Headache (doesn’t go away, more severe in acute SDH) Confusion and drowsiness Nausea & vomiting Slurred speech & changes in vision Dizziness, loss of balance, difficulty walking Weakness of one side of the body

15. Clinical Cont’d… 13 December 2023 Rebira W. ( AHN student) 15 Memory loss, disorientation, & personality changes (older adults with chronic SDH) Enlarged head in babies (as blood collects) As bleeding continues & the pressure in the brain increases, symptoms can get worse, symptoms at this point include: Paralysis Seizures Breathing problems Loss of consciousness

16. Investigations 13 December 2023 Rebira W. ( AHN student) 16 Initial routine bloods, including FBC, CRP, U & Es, LFTs PT & PTT → help in assessing for differential diagnosis CT scan is the gold-standard initial imaging modality for a suspected SDH A skull plain film radiograph- Pediatrics ( Mehta V, et al, 2023 )

17. Temporal Changes on CT Imaging 13 December 2023 Rebira W. ( AHN student) 17 Subdural hematomas will appear differently on CT imaging Acute-diffusely hyperdense Subacute-heterogeneously hyperdense or isodense Chronic SDH-diffusely hypodense ( Mehta V, et al, 2023 )

18. Differential Diagnosis 13 December 2023 Rebira W. ( AHN student) 18 (Mehta V, et al, 2023) For acute SDH Extradural hematoma Subarachnoid hemorrhage Intracerebral hemorrhage Intracerebral infarction For Chronic SDH Space occupying lesions Meningitis Encephalitis Dementia

19. Medical Management 13 December 2023 Rebira W. ( AHN student) 19 In an acute setting, do initial systematic A to E assessment Elevated ICP should also be managed appropriately Reversing anticoagulation appropriately Start anti-epileptic medications for 1 week after presentation of a SDH A SDH following a fall, investigate for potential underlying reasons for falls

20. Definitive Management 13 December 2023 Rebira W. ( AHN student) 20 Depend on the size & clinical features Not all cases require surgery Conservative management is generally appropriate for small acute SDH A surgical intervention called a trauma craniotomy flap required for an acute SDH- a large opening in the skull is created to evacuate the hematoma and relieve the associated mass effect

21. Definitive Cont’d… 13 December 2023 Rebira W. ( AHN student) 21 For large acute SDHs, there is often a significant mass effect present, therefore the bone flap is often left out at surgery, termed a decompressive craniectomy For chronic SDH, surgical intervention can be either a burr hole craniotomy with irrigation or a twist-drill craniotomy with drain placement- reduce recurrence rate & mortality without complications

22. 13 December 2023 Rebira W. ( AHN student) 22 Nursing Care Plan for SDH

23. Nursing Assessment 13 December 2023 Rebira W. ( AHN student) 23 1. Neurological assessment Do Glasgow coma scale Monitor pupillary response, assess change in size & reactivity Assess for motor strength and coordination Observe signs of neurological deterioration, such as changes in mental status, restlessness, or posturing

24. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 24 2. Vita Signs, oxygen therapy Monitor vital signs, BP, PR, RR, T o , pain & PSO2 Observe signs of increased ICP, such as ↑BP & bradycardia 3. Head injury assessment Assess mechanism of injury, time of occurrence, & any loss of consciousness 4. Pain assessment Assess pain using a pain scale, as head injuries can be painful & uncomfortable Note the location, intensity, & quality of the pain reported by the patient

25. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 25 5. Respiratory assessment Evaluate the patient’s respiratory status and auscultate lung sounds for any signs of aspiration or respiratory distress Assess for any signs of compromised airway or breathing difficulties 6. Gastrointestinal Assessment Monitor if client has nausea & vomiting, can be associated with increased ICP

26. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 26 7. Mental health assessment Assess the patient’s emotional state Provide emotional support during the assessment process Observe for signs of anxiety, confusion, or emotional distress 8. Medication and allergy review Obtain a list of the patients’ current medications & any known allergies Review medications that may affect clotting or increase the risk of bleeding

27. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 27 9. Past medical history Gather information if the client had any previous head injuries or bleeding disorders 10. Family history Inquire about a family history of bleeding disorders & neurological conditions

28. Nursing Diagnoses 13 December 2023 Rebira W. ( AHN student) 28 Acute Pain R/T the head injury and SDH Impaired verbal communication R/T potential aphasia, dysarthria, or altered mental status resulting from the SDH Anxiety R/T the uncertainty of the head injury’s outcome and the presence of the SDH Impaired Physical Mobility R/T neurological deficits and decreased muscle strength secondary to the SDH

29. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 29 Risk for decreased Intracranial adaptive capacity R/T the presence of a SDH causing increased ICP and potential compression of brain tissue Risk for Ineffective cerebral tissue perfusion R/T compromised blood flow and oxygenation caused by the SDH Risk for Infection R/T the possibility of surgical interventions to manage the SDH

30. Nursing Interventions 13 December 2023 Rebira W. ( AHN student) 30 1 . Neurological Monitoring Frequently assess level of consciousness, cognitive function, & pupillary responses Document Glasgow coma scale scores regularly to track changes in neurological status 2. Managing Pain Administer prescribed analgesics promptly to relieve pain and discomfort Use non-pharmacological pain relief measures such as positioning, or relaxation exercises

31. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 31 3. Mobilizing and Positioning Safe and controlled mobilization Appropriate positioning, maintain the head of the bed elevated to reduce ICP & optimize cerebral perfusion 4. Monitoring &managing ICP In collaborate with the healthcare team, monitor ICP readings, maintain a calm environment Minimize environmental stimuli, avoid activities that increase intrathoracic pressure

32. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 32 5. Preventing infection Strict aseptic techniques during wound care & invasive procedures to reduce the risk of infection. Provide prescribed antibiotics 6. Managing skin integrity Prevent pressure ulcers, such as frequent repositioning, the use of pressure-relieving devices, and regular skin assessments Keep the skin clean & dry

33. Nursing Cont’d… 13 December 2023 Rebira W. ( AHN student) 33 7. Reducing anxiety Address any concerns related to head injury and SDH Utilize relaxation techniques to help the patient cope with anxiety & promote a sense of calm (Arslan Sarwar, et al, 2023)

34. Complication If left untreated, coma and death Brain herniation Recurrent hematoma formation Seizures Raised ICP Cerebral edema 13 December 2023 Rebira W. ( AHN student) 34

35. Prevention 13 December 2023 Rebira W. ( AHN student) 35 Hematoma inevitable as a result of an accident, but the risks can be reduced Protecting your head Resting after a head injury Removing tripping hazards from the home Having vision checked regularly to prevent falls & accidents Having your healthcare provider do a medication review Drinking responsible Being careful when taking blood thinners

36. Prognosis 13 December 2023 Rebira W. ( AHN student) 36 Prognosis depends on: Age The severity of head injury and how quickly the client received treatment. About 50% of people with large acute SDH survive though permanent brain damage often occurs as a result of the injury Younger people have a higher chance of survival than older adults People with chronic SDH usually have the best prognosis Older adults have an increased risk of developing another hemorrhage after recovering from a chronic SDH

37. References 13 December 2023 Rebira W. ( AHN student) 37 Mashour GA, et al, (2006 ). Intracranial subdural hematoma and cerebral herniation after labor epidural with no evidence of dural puncture. Anesthesiology. Chen JC, et al, (2000). Causes, epidemiology, & risk factors of chronic subdural hematoma, Neurosurgery clinics of North America. Arslan Sarwar, et al, (2023). Nursing Care Plans. Kotwica Z, et al, (2018). Acute Subdural Hematoma in adults: an analysis of outcome in comatose patients.

38. 13 December 2023 Rebira W. ( AHN student) 38 MAY GOD BLESS YOU !