| Clinical features |
| Head trauma, especially to the temporal or occipital region. |
| Possible signs and symptoms include: |
| History of loss of consciousness |
| History of altered mental status per caregiver |
| Severe headache |
| Vomiting |
| Lethargy (GCS score 9 to 14) or coma (GCS score ≤8) |
| Irritability, pallor, cephalohematoma (infants ≤12 months) |
| Lucid interval for minutes up to several hours followed by clinical deterioration (classic temporal EDH) |
| Ataxia, dizziness with potential for abrupt catastrophic deterioration (posterior fossa EDH) |
| Lateralizing signs (anisocoria, hemiparesis, hemiplegia) and Cushing triad (hypertension, bradycardia, respiratory depression) are late findings that indicate cerebral herniation |
| Diagnostic evaluation |
| The primary goal is to make the diagnosis of EDH before neurologic deterioration in an asymptomatic or mildly affected child to permit timely surgical intervention. |
| Determine GCS score*; identify pupillary abnormalities and lateralizing motor findings. |
| Obtain emergency unenhanced head CT. |
| Obtain neurosurgical consultation for all patients with GCS score ≤12 or with identified EDH. |
| Initial laboratory studies (patients with EDH in need of surgical evacuation): |
| Complete blood count with platelets |
| Coagulation studies (PT, PTT with INR) |
| Type and crossmatch for blood transfusion |
| Other studies (eg, AST, ALT, and urinalysis) may be indicated in multiple-trauma patients¶ |
| Lumbar puncture is contraindicated. |
| Treatment |
| Surgical evacuation is the definitive management for EDH in children with altered mental status, signs of increased intracranial pressure, or focal neurologic findings. Such patients require emergency consultation with a neurosurgeon. |
| During stabilization, manage the patient according to principles of advanced trauma life support:¶ |
| Immobilize cervical spine |
| Treat hypoxemia |
| Assess and manage airway, breathing, circulation, and disability |
| Perform endotracheal intubation in children with GCS score ≤8 or rapidly worsening mental status; ventilate to maintain PCO2 between 35 and 40 mmHg |
| Provide fluid resuscitation, as needed, to prevent hypotension¶ |
| If signs of herniation, provide hyperosmolar therapy (preferably in consultation with a neurosurgeon):Δ |
| 3% hypertonic saline solution in a volume of 2 to 6 mL/kg IV per dose (maximum 300 mL), as a rapid bolus infusion. May repeat if needed or initiate infusion. Closely monitor serum sodium concentration and osmolarity (maintain <360 mOsm/L). |
| or |
| Mannitol 20% solution, 0.5 to 1 gram/kg IV per dose, as a rapid bolus infusion. May repeat after 6 hours as needed to increase serum osmolarity (maintain <320 mOsm/L). |
| Perform mild hyperventilation (PCO2 30 to 35 mmHg) for children whose signs of herniation do not respond to hyperosmolar therapy. |
EDH: epidural hematoma; GCS: Glasgow Coma Scale; CT: computed tomography; PT: prothrombin time; PTT: partial thromboplastin time; INR: international normalized ratio; AST: aspartate transferase; ALT: alanine transferase; PCO2: partial pressure of carbon dioxide; IV: intravenous.
* Utilize the pediatric GCS when indicated. Refer to UpToDate graphics on the GCS.
¶ Refer to UpToDate topics on trauma in the unstable child.
Δ Refer to UpToDate topics and graphics on the management of increased intracranial pressure in children.