Advanced Trauma Life Support ATLS Student Course Manual 2018

EVIDENCE-BASED TREATMENT GUIDELINES 111
an acute subdural hematoma is typically much
more severe than that associated with epidural
hematomas due to the presence of concomitant
parenchymal injury.
Contusions and Intracerebral Hematomas
A
C
n FIGURE 6-7 CT Scans of Intracranial Hematomas. A. Epidural
hematoma. B. Subdural hematoma. C. Bilateral contusions with
hemorrhage. D. Right intraparenchymal hemorrhage with right to
left midline shift and associated biventricular hemorrhages.
Epidural Hematomas
Epidural hematomas are relatively uncommon,
occurring in about 0.5% of patients with brain injuries
and 9% of patients with TBI who are comatose. These
hematomas typically become biconvex or lenticular in
shape as they push the adherent dura away from the
inner table of the skull. They are most often located
in the temporal or temporoparietal regions and often
result from a tear of the middle meningeal artery due
to fracture. These clots are classically arterial in origin;
however, they also may result from disruption of a
major venous sinus or bleeding from a skull fracture.
The classic presentation of an epidural hematoma is
with a lucid interval between the time of injury and
neurological deterioration.
Subdural Hematomas
Subdural hematomas are more common than epidural
hematomas, occurring in approximately 30%
of patients with severe brain injuries. They often develop
from the shearing of small surface or bridging
blood vessels of the cerebral cortex. In contrast
to the lenticular shape of an epidural hematoma
on a CT scan, subdural hematomas often appear to
conform to contours of the brain. Damage underlying
B
D
Cerebral contusions are fairly common; they occur
in approximately 20% to 30% of patients with severe
brain injuries. Most contusions are in the frontal and
temporal lobes, although they may be in any part of
the brain. In a period of hours or days, contusions
can evolve to form an intracerebral hematoma or a
coalescent contusion with enough mass effect to require
immediate surgical evacuation. This condition
occurs in as many as 20% of patients presenting with
contusions on initial CT scan of the head. For this
reason, patients with contusions generally undergo
repeat CT scanning to evaluate for changes in the
pattern of injury within 24 hours of the initial scan.
Evidence-bAsed Treatment
guidelines
Evidence-based guidelines are available for the
treatment of TBI. The 4th edition of the Brain
Trauma Foundation Guidelines for the Management
of Severe Traumatic Brain Injury were e-published
in September of 2016, and the print synopsis was
published in the Journal of Neurosurgery in January of
2017. The new guidelines are different in many ways
from the old guidelines. New levels of evidence are
labeled from highest quality to lowest: levels I, IIA, IIB,
and III.
The first guidelines addressing TBI, Guidelines for
the Management of Severe Traumatic Brain Injury, were
published by the Brain Trauma Foundation in 1995,
revised in 2000, and updated most recently in 2016.
Additional evidence-based reviews have since been
published regarding the prehospital management of
TBI; severe TBI in infants, children and adolescents;
early prognostic indicators in severe TBI; and combatrelated
head injury. The Brain Trauma Foundation TBI
guidelines, which are referenced in this chapter, can be
downloaded from the foundation website: http://www.
braintrauma.org. In addition, the American College
of Surgeons Trauma Quality Improvement Program
(TQIP) published a guideline for managing TBI in 2015.
(See ACS TQIP Best Practices in the Management of
Traumatic Brain Injury.)
Even patients with apparently devastating TBI on
presentation can realize significant neurological re-
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