Neurology
Subdural hematoma forms as a result of collection of blood underneath the inner layer of dura matter but external of the brain and arachnoid matter (Gaist et al., 2017). The main understanding of subdural hematoma rests on the knowledge of neuroanatomical layers covering the brain. The brain is the core repository of frail neural tissue. The network of neuronal and neuron connecting tissue is vulnerable to injury without the scalp and bony structure of the cranium. The brain gets protected by three layers whereby the dura matter and arachnoid matter are found. Subdural hematoma is believed to cause increase of pressure inside the skull, whereby it can in turn cause compression and damage of delicate tissues of the brain. Acute subdural hematoma is usually life threatening while chronic subdural hematoma has better prognosis when properly handled. Blood often accumulates in between the dura matter and arachnoid matter and can cause ischemic damage to the brain through two mechanisms. One is by the pressure on the cortical blood ducts, and secondly vasoconstriction as a result of substances produced from hematoma which leads to further ischemia by blood restriction into the brain. When the brain gets repudiated adequate flow of blood, a biochemical cascade referred to as ischemic cascade is released and can lead to death of brain cells. Subdural hematoma continues to grow larger due to pressure they assert on the brain. As intracranial pressure escalates, blood gets squeezed in the Dural venous sinuses, increasing the Dural pressure and lead to more bleeding from the ruptured bridging veins.
The management of this patient depends greatly on the bleeding extend and overall clinical evaluation. Tiny, asymptomatic subdural hematoma can get managed conservatively by serial CT scans of the skull to examine for any interval deviation in hemorrhage size. Large hemorrhage or the one producing more significant medical compromise, should get evaluated immediately for surgical decompression. The immediate management of the patient with extreme bleeding between the dura matter and the arachnoid initially starts with assessing the airway, breathing, circulatory (ABC’s) system for critical care personnel (Pierre & Kondamudi, 2019). The medical personnel listen and feels for airway obstruction. If the patient’s breath sounds quiet, then air entry ought to get confirmed through placement of face or hand in the fore front of patient’s nose and mouth to ascertain airflow by observing the abdomen and chest for equal chest expansion or else breathing sound using stethoscope. Again, the medical personnel need to make sure that the patient’s blood is flowing and circulating.
Despite the prompt in surgical evaluation of subdural hematoma, the patient may have poor prognoses as a result of associated underlying damage of the brain. The levels of alertness ought to get noted by use of Glasgow Coma Scale. Patients with Glasgow Coma Scale reading less than 8.0 ought to get intubated for airway protection (Majdan et al., 2015). Rapid sequential intubation is done with enough sedatives to curb and raise intracranial pressure. Normocapnia together with mild hyperoxemia are maintained to stop secondary brain damage. The patient requires intensive care carried out postoperatively for the ventilator-dependent respiration, blood pressure control carried out strictly, and managing of intracranial hypertension. The pupillary examination showed inequality between the two pupils. This examination is among the few neurologic symptoms that can get assessed in unconscious patient. This examination is minimal invasive assessment which gives valuable data about the progression and severity of the brain injury in conjunction with brainstem functionality. The examination should get undertaken whereby the medical personnel aids the patient to focus on distant objects directly ahead. Any focal neurological abnormality calls for activation of emergency medical services.
Blood pressure, heart beat rate, and respiratory are high due to increased intracranial pressure. Intravenous mannitol, cerebrospinal fluid drainage, and use of vasopressors get used to maintain cerebral perfusion pressure to at least 50-70 mm Hg. The administration of mannitol or hypertonic saline helps in decreasing intracranial pressure through promotion of osmotic alterations in the brain and momentarily impacting rheological materials of cerebral blood flow (Boone et al., 2015). Adequate oxygenation gets administered to the patient in order to maintain Sp02 more than 95 percent, head elevation, moderate hyperventilation of Pc02 (32 – 36), and sedation are among the immediate medical management the clinician ought to administer to the patient.
The medical group should refer to neurosurgical consultation early enough into managing the patient. A pediatric neurologist is also crucial on top of the consulting physicians. An ophthalmology consultant with complete assessment of the patient’s retina is essential while assessing the patient.
There are several principles of intracranial pressure (ICP) management and care towards patient’s post-neurosurgery to bring the patient to total recuperation. First, the patient’s bed should get elevated to a minimum of 30 degrees as clinically tolerated in order to lower aspiration of the contaminated oropharyngeal secretion and successive development of ventilator associated pneumonia (Yadav et al., 2016). Secondly, keeping neck midline in order to facilitate venous drainage from the head. Administration of hypercarbia helps in reducing the serum pH and increase cerebral flow of blood leading to the rise of intracranial pressure and thus hyperventilation lowering Pco2 to 30 mm Hg which can get transiently utilized. Also, osmotic agents ae used in creating osmotic pressure across blood flow thereby drawing fluids in intravascular manner and lowering cerebral edema. Mannitol agent get used in exerting its great benefit of lowering blood viscosity and consequently lowering blood volume. Three percent of hypertonic saline is also used in decreasing cerebral edema and administered in 5ml per kilogram or continual infusion while monitoring serum sodium ranges closely. Drugs in the class of carbon anhydrase inhibitors like acetazolamide can get used to the patient in order to decrease production of cerebrospinal fluids and is also used to treat intracranial hypertension.
Nursing care ought to pay much attention to alterations in neurologic state and any change in the majors like increasing erratic heart rate, developing of bradycardia, equal and accurate output and intake when the patient is having diuresis, and maintenance of moderate blood pressure. As the patient crawls on his way to recovery, occupational therapy, physical therapy, and speech language therapy can aid the patient to maximize functionalities after brain injury and examine patient safety before and after his dismissal. Patient’s sensitization regarding avoiding future complications ought to come from all team members, together with social work inclusion in ensuring safety of motorists and patient’s primary care giver updated in ensuring efficient follow up after discharge. The care giver also has to be educated on the watch over the patient’s need for re-admission because of recurrence or complications.
In summary, a complete management strategy aims on supporting the airway, maintaining adequate oxygenation, supporting efficient cerebral perfusion without increasing intracranial pressure and lowering the cerebral metabolism rate are crucial for positive results in a patient with brain injury. The effort is best attained through coordination and collaboration amongst emergency departments, neurology and neurosurgery teams, critical care group, radiology suites, and respiratory therapists. However, the prognosis depends on the extend of the injury. The patients with minimal brain injury have better outcomes.
References
Gaist, D., Rodríguez, L. A. G., Hellfritzsch, M., Poulsen, F. R., Halle, B., Hallas, J., & Pottegård, A. (2017). Association of antithrombotic drug use with subdural hematoma risk. Jama, 317(8), 836-846.
Pierre, L., & Kondamudi, N. P. (2019). Subdural Hematoma. In StatPearls [Internet]. StatPearls Publishing.
Yadav, Y. R., Parihar, V., Namdev, H., & Bajaj, J. (2016). Chronic subdural hematoma. Asian journal of neurosurgery, 11(4), 330.
Majdan, M., Steyerberg, E. W., Nieboer, D., Mauritz, W., Rusnak, M., & Lingsma, H. F. (2015). Glasgow coma scale motor score and pupillary reaction to predict six-month mortality in patients with traumatic brain injury: comparison of field and admission assessment. Journal of neurotrauma, 32(2), 101-108.
Boone, M. D., Oren-Grinberg, A., Robinson, T. M., Chen, C. C., & Kasper, E. M. (2015). Mannitol or hypertonic saline in the setting of traumatic brain injury: what have we learned?. Surgical neurology international, 6.