Rosen & Barkin's 5-Minute Emergency Medicine Consult (684 page)

• Acute
  
• Early neurosurgical intervention (<4 hr) in comatose patients shows reduced mortality:
  
  • Burr holes may be used as temporizing measure in deteriorating patients.
    
  • ICP monitoring is indicated for patients with abnormal CT who are intubated.
    
  • Subdural evacuating port system has been shown to be equivalent to Burr hole for acute treatment of SDH
    
• Nonoperative treatment may be indicated for small SDH:
  
  • <20 mL of blood, <1 cm, midline shift <5 mm, no mass effect, no neurologic deficit
    
  • This requires frequent neurologic reassessment.
    
  • 10% go on to require operative intervention.
    
• Maintain euvolemic state with isotonic fluids:
  
  • Arterial line placement to monitor MAP, PO
    ₂
    , and PCO
    ₂
    
  • Foley catheter to monitor I/O status
    
• Control ICP:
  
  • Prevent pain, posturing, and increased respiratory effort:
    
    • Sedation with benzodiazepines
      
    • Neuromuscular blockade with vecuronium or rocuronium in intubated patients
      
    • Etomidate is a good induction agent.
      
  • Mannitol may be used once euvolemic:
    
    • Shown to increase MAP > cerebral perfusion pressure and CBF as well as decrease ICP
      
  • Keep osmolality between 295 and 310.
    
  • Use furosemide (Lasix) as an adjunct only if normovolemic.
    
  • Treat HTN:
    
    • Labetalol, nicardipine, or hydralazine
      
  • Treat coagulopathy
    
  • Use fresh frozen plasma 4+ units
    
  • Use prothrombin complex concentrate
    
  • Treat hyperglycemia if present:
    
    • Associated with increased mortality in traumatic brain injury
      
  • Treat and prevent seizures:
    
    • Diazepam and phenytoin (Dilantin), levetiracetam: Prophylactic anticonvulsants not indicated
      

• Diazepam: 5–10 mg (peds: 0.2–0.3 mg/kg) IV/IM q10–15min PRN; max. 30 mg (peds: 10 mg)
  
• Dilantin: Adults and peds: Load 18 mg/kg at 25–50 mg/min
  
• Etomidate: 0.3 mg/kg IV for induction of RSI
  
• Fentanyl: 2–4 μg/kg
  
• Hydralazine: 10–20 mg (peds: 0.1–0.5 mg/kg IV) q2–4h PRN
  
• Labetalol: 20 mg IV bolus, then 40–80 mg q10min; max. 300 mg; follow with IV continuous infusion 0.5–2 mg/min; (peds: 0.4–1 mg/kg/h IV continuous infusion; max. 3 mg/kg/h)
  
• Lasix: Adults and peds: 0.5 mg/kg IV
  
• Levetiracetam: 1,500 mg PO/IV q12h
  
• Lidocaine: As preinduction agent, 1.5 mg/kg IV
  
• Mannitol: Adults and peds: 0.25–0.5 g/kg IV q4h
  
• Midazolam: 1–2 mg (peds: 0.15 mg/kg IV × 1) IV q10min PRN
  
• Nicardipine: 5–15 mg/h IV continuous infusion (peds: Safety not established)
  
• Pentobarbital: 1–5 mg IV q6h
  
• Prothrombin complex concentrate: 50 U/kg IV
  
• Rocuronium: 1 mg/kg for induction
  
• Thiopental: As induction agent, 20 mg/kg IV
  

FOLLOW-UP

• Acute SDH patients should be admitted to the operating room or ICU by the neurosurgical service.
  
• Subacute subdurals should be admitted to a monitored setting.
  

Patients with chronic SDH often can be managed as outpatients in conjunction with neurosurgery, adequate home resources, and appropriate follow-up.

All patients need neurosurgical evaluation immediately.

The following factors predict prognosis:

• GCS on admission
  
• Time to treatment
  
• Pupil abnormalities
  
• CT volume of hematoma and presence of midline shift
  
• Midline shift > hematoma volume
  

• Beslow LA, Licht DJ, Smith SE, et al. Predictors of outcome in childhood intracerebral hemorrhage: A prospective consecutive cohort study.
  Stroke
  . 2010;41(2):313–318.
  
• Chittiboina P, Cuellar-Saenz H, Notarianni C, et al. Head and spinal cord injury: Diagnosis and management.
  Neurol Clin.
  2012;30(1):241–276, ix.
  
• Huh JW, Raghupathi R. New concepts in treatment of pediatric traumatic brain injury.
  Anesthesiol Clin
  . 2009;27(2):213–240.
  
• Krupa M. Chronic subdural hematoma: A review of the literature. Part 2.
  Ann Acad Med Stetin
  . 2009;55(3):13–19.
  
• Kubal WS. Updated imaging of traumatic brain injury.
  Radiol Clin North Am
  . 2012;50:15–41.
  
• Zhu GW, Wang F, Liu WG. Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging.
  J Int Med Res
  . 2009;37(4):983–995.
  

CODES

• 432.1 Subdural hemorrhage
  
• 767.0 Subdural and cerebral hemorrhage
  
• 852.20 Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness
  

BASICS

• Sudden, unexpected death of an infant <1 yr old who was typically well before being placed down to sleep
  
• Death remains unexplained after being thoroughly investigated by autopsy, exam of the death scene, investigation of the circumstances, and review of the family and infant medical histories.
  
• Leading cause of death in infants 1 mo–1 yr of age; the incidence has declined markedly since the initiation of the “Back to Sleep” program in 1994:
  
  • 1992: 120 deaths/100,000 live births (US)
    
  • 2001: 56 death/100,000 live births (US)
    
  • No change from 2001–2006
    
• Peak occurrence of SIDS at 1–4 mo of age:
  
  • 90% occur <6 mo of age
    
  • 2% occur >10 mo of age
    
• Ethnic differences: 2006 rates per 100,000 live births: All populations, 54.5; non-Hispanic white, 55.6; non-Hispanic black, 103.8; American Indian/Alaska Natives, 119.4; Asian American or Pacific Islander, 22.8; Hispanic, 27.
  
• Sleeping on back (supine) reduces incidence significantly (“Back to Sleep”). Practice of infants sleeping on their backs began initially in Europe and then in US
  

• Most likely multifactorial
  
• SIDS infants likely have predisposing conditions that make them more vulnerable to both internal and external stressors.
  
• Potential stressors include anemia, congenital diseases, dysrhythmias, electrolyte abnormalities, genetic defects, infection, metabolic disorders, neurologic events, suffocation, trauma, upper airway obstruction.
  
• Maternal and antenatal risk factors:
  
  • Alcohol and illicit drug use
    
  • Intrauterine growth restriction
    
  • Lower socioeconomic status
    
  • Poor prenatal care
    
  • Prior sibling death secondary to SIDS
    
  • Shorter interval between pregnancies
    
  • Smoking
    
  • Younger age
    
• Infant risk factors:
  
  • Bed sharing
    
  • Exposure to environmental smoking
    
  • Gastroesophageal reflux (GER)
    
  • Hyperthermia
    
  • Low birth weight, prematurity
    
  • Male gender
    
  • Soft bedding, soft sleeping surface
    
  • Recent febrile illness
    
• Supine sleeping position, breast-feeding, and pacifier use are protective.
  
• Home monitoring has not been shown to prevent SIDS.
  

DIAGNOSIS

• No significant pre-existing signs or symptoms to alert caretakers
  
• Unpredictable
  
• Most infants appear normal when put to bed.
  
• Death occurs while the infant is sleeping.
  
• Typically the event is silent with no signs of struggling.
  
• No clinical or pathologic explanation for death.
  
• Apparent life-threatening event (ALTE) is an acute event that is frightening to the caretaker:
  
  • Characterized by apnea (either central or obstructive) causing changes in skin color—cyanosis, pallor, or erythema with limpness, choking, and/or gagging.
    
  • Infant should be transported to hospital for evaluation and monitoring.
    
  • Appears well when evaluated by clinicians after recovery from ALTE.
    
  • Associated with an increased risk of SIDS.
    

• Prior to the event, the infant is seemingly healthy and well appearing, well developed, and well nourished.
  
• If event was brief and self-limited, may appear well when evaluated after the episode.
  
• Potential complications for surviving infants include pulmonary edema, aspiration pneumonia, and neurologic sequelae secondary to hypoxia including seizures.