Jurding_Multidisciplinary_Approach_to_the_Management_of_Traumatic.pptx

management trauma pada edh, treatment dn konsultasinya

1. Multidisciplinary Approach to the Management of Traumatic Epidural Hematoma: Pathophysiology, Treatments, and Outcomes Department of General Surgery Faculty of Medicine, Universitas Padjadjaran Dr. Hasan Sadikin General Hospital Bandung

2. ABSTRACT

3. INTRODUCTION

4. INTRODUCTION EDH is a collection of blood between the duramater and the inner surface of the skull. Early recognition and coordinated multidisciplinary care improve outcomes and prevent neurological deterioration Often results from arterial bleeding due to traumatic brain injury ; characterized by the " lucid interval " phenomenon, requiring vigilant clinical monitoring. Delayed treatment can lead to severe complications.

5. INTRODUCTION Advanced imaging techniques, particularly computed tomography (CT) scans, are crucial for diagnosis and determining hematoma severit Effective management requires a multidisciplinary approach ; early surgical evacuation improves prognosis. Further investigation is needed to improve current treatment strategies, develop more advanced imaging techniques, and discover novel therapies to address the remaining challenges in epidural hematoma management.

6. EPIDEMIOLOGY

7. 2 % of cases , up to 15% of such deaths . Higher incidence in males , especially adolescents and young adults ; mean age 20-30 years old Higher prevalence in younger populations is linked to increased exposure to high-energy traumas like sports injuries and vehicular accidents. EDH is less common in individuals over 50 to 60 years of age. Age-related anatomical changes, including the duramater's firmer adhesion to the skull; decreased potential space for blood accumulation; and reduced vascularity and elasticity of the dural membrane.

8. PATHOPHYSIOLOGY

9. The most common cause of EDH is bleeding from an injured artery. In most cases, the bleeding originates from the middle meningeal artery. V enous bleeding (10%); typically involves lacerations of the dural venous sinuses. Location of EDH : Adults : Most frequently observed in the temporal region (approximately 75% of cases). Children : More evenly distributed across the temporal, occipital, frontal, and posterior fossa regions. This reflects differences in cranial development and injury patterns

10. EDH can be classified based on its appearance on imaging over time: Acute EDH (within 24 hours) : Characterized by a swirl of unclotted blood on imaging. Subacute EDH (days 2-4) : Presents as a solid hematoma. Chronic EDH (over 7-20 days) : Appears as a mixed or lucent lesion, possibly with contrast enhancement.

11. CLINICAL PRESENTATION

12. Observed in approximately 14% to 21% of cases, the classic presentations of EDH are : Initial loss of consciousness after the trauma. A transient lucid interval (period of apparent recovery). Not all patients experience a lucid interval. Some patients may remain unconscious , while others may exhibit no initial loss of consciousness. Subsequent neurological deterioration. Small EDHs may remain asymptomatic, while rapid hematoma growth can lead to signs of increased intracranial pressure (ICP).

13. Patients may remain conscious until late in the disease course; Sudden decompensation characterized by apnea (cessation of breathing) and coma. Ipsilateral pupil dilation Bradycardia Signs of Increased Intracranial Pressure (ICP) : Irregular respiration. Posterior fossa EDH (rare) comprises approximately 5% of all cases. H ypertension

14. SIGNIFICANCE OF EARLY INTERVENTION The outcome for EDH patients is strongly linked to how quickly they are diagnosed and treated. Surgically removing the hematoma is the main treatment, except for a few patients with small, stable hematomas who may be managed without surgery. Advances in brain imaging, particularly CT scans , have significantly improved the ability to detect EDH early.

15. EVALUATION

16. CT Scans considered the gold standard for diagnosing EDH. Typically appears as a biconvex or lens-shaped hyperdense mass. The hematoma is confined by the dura's attachment to cranial sutures, preventing spread across suture lines. Low-density areas or the "swirl sign" indicate active bleeding. International Normalized Ratio (INR) Partial Thromboplastin Time (PTT) Laboratory Tests : Prothrombin Time (PT) Liver Function Tests (LFTs) Purpose: To assess bleeding risk or detect underlying coagulopathies

17. For detecting vertex EDH , and spinal EDH Magnetic Resonance Imaging (MRI) May be necessary in cases involving vertex EDHs. Used to investigate potential dural arteriovenous (AV) fistulas originating from the middle meningeal artery. Angiography

18. TREATMENT & MANAGEMENT

19. Initial Stabilization The first step is stabilizing the patient's airway, breathing, and circulation (ABCs). Early surgical evacuation (within 1-2 hours of presentation) significantly improves outcomes. Once stable, patients with acute EDH are evaluated for surgical intervention. Surgery is indicated if: Hematoma exceeds 30 mL, regardless of GCS score. GCS score is less than 9 with pupillary abnormalities (e.g., anisocoria).

20. Gold Standard : Craniotomy and Hematoma Evacuation Alternative : Burr Hole Evacuation ( Trephination) Operative Management Conservative Management Criteria : May be considered for select patients with mild symptoms who meet specific criteria: Non-Operative Management Hematoma volume < 30 mL Clot diameter < 15 mm Midline shift < 5 mm GCS > 8 without focal neurological deficits

21. DIFFERENTIAL DIAGNOSIS Intracranial Abscess Intracranial Mass Seizure Transient Ischemic Attack (TIA)

22. PROGNOSIS

23. Generally favorable for isolated EDHs when promptly diagnosed and surgically managed. Hematomas > 50 cm³ before evacuation are associated with poorer neurological outcomes and higher mortality rates. Arterial bleeding (rapid development): Allows quicker detection; while dural sinus tears (slower development): Leads to delayed recognition and intervention Factors Influencing Prognosis include: patient age, time between injury and treatment, presence of coma or lucid interval, pupillary abnormalities, Glasgow Coma Scale (GCS) or motor score at presentation

24. Low GCS score at presentation Unreactive pupils Postoperative ICP is a key prognostic indicator. Advanced age Poor Prognostic Markers Delays in surgical intervention Hematoma volumes between 30 and 150 mL Midline shifts > 10-12 mm Postoperative Intracranial Pressure "Swirl sign" indicating active bleeding Concurrent lesions (subarachnoid hemorrhages, diffuse cerebral edema)

25. Seizures can result from irritation of brain tissue by the hematoma or elevated ICP. Accumulating blood exerts pressure on the brain, causing compression and damage, increasing ICP. Outcomes of Untreated/Late-Diagnosed EDH can lead to permanent neurological impairment or death. Early recognition, imaging, and surgical evacuation are crucial. Rising ICP can lead to brain herniation , compressing critical structures like the brainstem. Complications

26. Neurosurgical and Trauma Teams should be involved as soon as an EDH is suspected. Neurosurgeons determine the need for surgical intervention and provide postoperative care. Trauma Surgeons stabilize the patient (ABCs) Timely Neurosurgical Consultation : Crucial for treatment success. Delays increase the risk of irreversible neurological damage or death Other Specialists : Neurologists (seizures), critical care teams (ICP management). Consultations

27. Pharmacist assess the patient’s medication history anticoagulation therapy or coagulopathy . Assist in pain management, seizure prophylaxis, and the prevention of complications like infections . Reducing the risk of adverse drug interactions Nurse continuous monitoring and care of EDH patients, both pre- and postoperatively. M ultidicipline

28. Roles of Emergency Providers, Pharmacists, and Nurses

29. CONCLUSION

30. The successful management of EDH highlights the critical role of collaboration and a shared commitment to patient care in emergency medicine.

31. Thank You