HPI

• 18 yo male restrained front seat passenger T boned by a tractor trailer on the driver’s side
• Airbags were deployed
• Patient was ambulatory at the scene of the accident
• Pt c/o headache and nausea. Pt states repetitively “I don’t know. I don’t know. My head hurts.” 

Physical Exam

• VS: T 98.4, HR 74, BP 135/78, RR 18, Pulse ox 99% on room air
• General: Patient is awake, alert, laying on stretcher. Appears uncomfortable. Oriented to person, place, and time GCS 15
• Hematoma on L side of head just above the temple
• No midline C spine tenderness
• Neuro: CN intact, normal strength and sensation in all extremities. Gait is normal
• Abdomen soft and nontender
• Just after finishing exam, patient vomits

Diagnostics

CT head, noncontrast, image below

Interpretation: Fracture of the L sphenoid wing with underlying localized epidural hematoma

Management

• Neurosurgery and trauma consults
• Blood pressure control to under SBP 120
• Head of bed elevated to 30 degrees
• Antiemetics, NPO
• Seizure prophylaxis with levetiracetam
• Patient was taken to the OR for middle meningeal artery embolization to prevent worsening of bleed 

Take-home points

• Epidural hematoma is a collection of blood in the potential space between the skull and the dura
• Because the bleed is often arterial in nature, the hematoma can rapidly expand, causing quick neurologic decline
• Often pt has initial LOC, then is conscious and lucid, followed by rapid decline from hematoma expansion and increased ICP aka "the lucid interval"
• This patient warranted a CT head as he had amnesia to the event, had a normal GCS but some confusion evidenced by repetitive answers, and vomiting in the ED
• CT head without contrast is the diagnostic study of choice and will show a biconvex (lens shaped) collection of blood that does not cross suture lines (because it is in epidural space)
• Management often includes craniotomy for hematoma evacuation, but sometimes can include endovascular embolization of the middle meningeal artery

References Wright, DW, Merck, LH. Head Trauma. Tintinalli’s Emergency Medicine. Ch 257, 1695-1707.