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PATOPHYSIOLOGY AND DIAGNOSIS OF EDH & BASIC

PRINCIPLES OF DEPRESSED FRACTURE


MANAGEMENT

THE ANATOMY

BLUNT
1. HIGH
VELOCITY
2. LOW
VELOCITY

Mechanis
m of
Injury

IMPACT

PENETRAT
ING
1. STAB
WOUND
2. GUN
SHOT
3. OTHERS

EPIDURAL HEMATOMA

Accumulation of blood in the


potential space between dura mater
and bone

PATHOPHYSIOLOGY

Dissection of the dura from the inner table


may occur first, followed by bleeding in the
space thus created

Source of bleeding : 85% from arterial


disruption, especially of the middle
meningeal artery. Rarely from venous sinus.

COMPRESSION-MIDLINE
SHIFT & MASS EFFECT
SYMPTOMS AND SIGNS

CLINICAL FINDING
10-27% have this classical
presentation :
Brief post traumatic loss of
consciousness (LOC) followed by a
Lucid interval for several hour.
Then, obtundation, contralateral
hemiparesis, ipsilateral pupillary
dilatation

OTHER CLINICAL FX MAY PRESENTS :

Headache
Vomiting
Seizure
Ipsilateral dilated pupil
Contralateral hemiparesis. But ipsilateral
hemiparesis may occur (Kernohans
phenomenon), a false localizing sign
Bradicardia is a late findings
Hypovolemia may be present in infant

HOW TO DIAGNOSE ?
1.

ENSURING THE DIAGNOSIS :


ANAMNESIS AND PHYSICAL EXAM
RADIOLOGIC EVALUATION, BY :
Plain Skull X-Ray.
No fracture is identified in 40%
CT Scan
Density biconvex (Lenticular) shape
hematoma.

TREATMENT
A, B, C, D
2. Oxygenation
3. Head up 300
4. IVFD
5. Analgetic
6. Antibiotic if necessary
7. Anticonvulsant prophylactic
8. H-2 Blocker
9. NGT, Foley Catheter
10. Determine : Conservative or Surgical ?
1.

TREATMENT
NON SURGICAL, If :
Small lession (< / = 1 cm maximal
thickness) non acute EDH with minimal
neurological signs/symptoms and no
evidence of herniation
Volume < 30 cm 3
Mid line shift < 5 mm
GCS > 8
No focal neurologic defisit

NON SURGICAL, by : Observe in


monitored bed with CT serial in 1 week
if clinically stable, and may repeat 1-3
times if ptx becomes asymptomatic .

SURGICAL BY CRANIOTOMY
EVACUATION, If :
Signs of local mass effect, signs of
herniation (increasing drowsiness, pupil
changes, hemiparesis,), or
cardiorespiratory abnormality.
Strongly recommended in acute EDH &
GCS < 9 and anisocoria

DELAYED EPIDURAL HEMATOMA (DEDH)

An EDH is not present on the initial CT,


but is found in subsequent CT. 9-10% of
all EDH
Risk Fx : Lowering ICP either medically
or surgically which reduces
tamponading effect, Rapidly correcting
shock, Coagulopathies
Key to Dx : High index of suspicion

DEPRESSED SKULL FRACTURE

Classified as Simple (Closed) and Compound


(Open) Fracture

Pressing in
externa
table of the
skull at the
site of injury

Strain force
of internal
table

FRACTURE

Force
increase
exceeds the
capability of
bone
deformation

This type of fracture occur if the


magnitude of energy of trauma is
relatively bigger towards the
traumas area which is relatively
smaller (ex, hammer, wood, stone,
pipe, etc)
In plain skull X-ray will appear double
densitys area

SIGNS/SYMPTOMS

Headache
LOC
Mass effect
Compression effect
Signs Infection, locally or systemic

CONSERVATIVE MANAGEMENT IN DEPRESSED SKULL


FRACTURE

Open (Compound)
a. There is no evidence of dural penetration
(clinically or CT). Ex, CSF leak
b. No significant intracranial hematoma
c. Depression is < 1 cm
d. No frontal sinus involvement
e. No wound infection or gross contamination
f. No gross cosmetic deformity

SURGICAL MANAGEMENT IN DEPRESSED SKULL


FRACTURE

If depressed is more than calvaria thickness


Those not meeing the criteria for thr conservative
treatment
The Principles of surgery :
1. Debridement of skin edges
2. Elevation of bone fragments
3. Repair of dural laceration
4. Debridement of devitalized brain
5. Reconstruction of the skull
6. Skin closure