Not Just a Knock to the Head

• Outdoor activities such as skateboards, bikes, rolling skates, etc can be dangerous if one falls without protective gear. 
• A subdural hematoma is a serious traumatic brain injury with a high mortality rate between 60-80%. 
• Follow along as we evaluate a case study on a patient who suffered a subdural hematoma. May this be a reminder to wear protective gear and helmets when engaging in outdoor activities.

You are the charge nurse in the emergency room, and you receive traffic that emergency medical services (EMS) are transporting a 17-year-old female after a fall while longboarding.  

According to bystanders, there was a brief loss of consciousness after the fall. She was awake and alert upon initial EMS evaluation with a Glasgow Coma Scale (GCS) of fifteen.  

Paramedics placed the patient into a c-collar and immobilized her on a spine board.  

On the way to the hospital, there was a change in her mental status. Following her initial lucid interval, the patient develops confusion and vomiting.

Her vital signs on the ambulance: heart rate of fifty-two beats/minute, a respiratory rate of eight breaths/minute and a blood pressure of 147/102 mmHg. Her pulse oximetry is 98% on room air. The paramedic noted her pupils were equal, round, and reactive at 3mm. 

Trauma Evaluation

In the ED, trauma physicians conduct a primary and secondary trauma assessment, noting the patient’s chest is symmetric and without deformity.  

Upon auscultation, her lungs are clear, and her heart rhythm is regular. Her abdomen is without bruising, soft, non-tender, and non-distended. She is moving her extremities.  

The patient denies midline cervical tenderness and vague complaint of occipital pain.  Her c-collar remained in place secondary to her altered mental status.  

The team establishes their differential diagnosis: subdural hematoma (SDH), subarachnoid hemorrhage (SAH), epidural hematoma (EDH), and potential skull fracture.

Radiological Findings of Subdural Hematoma

After the initial exam, the primary nurse transports to patient to the CT scanner. The CT scan of the head and neck shows a simple subdural hematoma without parenchymal contusion and a small region of active hemorrhage in the posterior region. There is no midline shift. 

Because of her fall, your patient has suffered a traumatic brain injury (TBI), a minor skull fracture, and a subdural hematoma.  

After a consult with neurosurgery, it is determined that the patient will not require surgical intervention. The neurosurgery service admits the patient for observation.  

During the patient’s hospital stay the patient receives anticonvulsants to prevent seizures, and a repeated CT scan to monitor the hematoma.  

The second CT, six hours later, showed a notable reduction of the hematoma and with improving neurological function. 

What Is a Subdural Hematoma?

With head trauma, the sudden and shearing forces from the impact can strain the blood vessels within the dura. This can cause the blood vessels to rip and bleed at the bridging veins located in the subdural space. Small arteries can rupture, and blood can collect between the dura and arachnoid layers of the meninges.  

This physiologic presentation, referred to as a subdural hematoma (SDH), where the blood forms between the dura and the arachnoid membranes can be acute or chronic.  

Subdural hematomas are often venous and self-limited by the increasing intracranial pressure. A SDH of significant size can disrupt the physiologic flow of cerebrospinal fluid, and a SDH that persists over 3 weeks, is chronic.  

An acute subdural hematoma can occur in up to thirty percent of people with severe head injuries.  

Outlook and Prognosis of a Subdural Hematoma

After her brief hospital stay, they discharged the patient. Per family she complained of the occasional ongoing headache and drowsiness and the patient experienced mild confusion for thirty days after discharge.  

In her case the bleeding was slow, and the elasticity in her young brain absorbed the pooled blood.  

Discharge instructions include limited activity and the potential for seizures weeks after the initial (traumatic) event. Discharge instructions for the patient and family included no contact sports, bike riding, skate, or longboarding until cleared by her primary care doctor.  

The Bottom Line on Subdural Hematoma

Head injuries without loss of consciousness, require medical attention. As nurses, promoting safety is an essential ethos.  

The American Academy of Pediatrics recommends wearing a helmet that meets safety standards (ASTM F1492 or Snell N-94), in addition to wrist guards, knee and elbow pads, flat-soled shoes. The academy advised that children under the age of five not ride longboards, and children ages 5-10 have supervision.  

This patient was fortunate that her head injury was not more severe. Subdural hematomas can be life-threatening, and for the elderly the diagnosis carries a substantial risk of death and disability. A traumatic acute subdural hematoma can be a neurosurgical emergency with mortality  as high as 60% to 80%. About half of the patients with large acute hematomas survive, though permanent brain damage can occur secondary to the trauma.  

Helmets for longboarders, bikes, hoverboards and other outdoor recreation activities can reduce head trauma and the potential catastrophic outcomes. 

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