Subdural Hematoma: APEI Scenario

Subdural hematoma involves a blood clot forming between the dura mater and the brain, specifically in the inner lining of the dura mater and arachnoid mater.
This condition typically arises from tearing or damage to bridging veins within the subdural space.

Trauma to the head is the most prevalent cause.
Falls in the elderly, especially those on blood thinners (anticoagulants), are a significant risk factor.
Chronic alcoholism can lead to brain shrinkage, causing tearing of bridging veins.

Chronic Subdural Hematoma: Develops slowly over time.
Acute Subdural Hematoma: Results from immediate trauma causing rapid bleeding.

Loss or reduced level of consciousness (GCS of 14 instead of 15).
Headache accompanied by nausea and vomiting due to increased intracranial pressure.
Potential seizures.
One-sided weakness (hemiparesis) or total paralysis (hemiplegia) on the opposite side of the clot.

Diagnosis: CT scan is essential for confirmation.
Surgery:
- Craniotomy: Removal of the bone to remove the blood clot, followed by bone replacement.
- Burr Holes: Drilling to release the blood clot.
Conservative Management: Small subdural hematomas may be monitored without immediate intervention, allowing the body to break down and remove the clot naturally.

The scenario typically occurs in a hospital setting.
The patient is often confused and disoriented (GCS of 14).
Reorient the patient actor, reassure them of their safety, and provide context regarding the hospital and time.
Expect pain and headache, a history of falls, and potential vomiting and nausea.
Consider the patient's home environment, including accessibility challenges and available support (relatives, care packages).

Complete a full GCS in addition to the A to E assessment.
Prioritize and expedite the A to E assessment to allocate sufficient time for the GCS.
Key Principles: Safety, privacy, hand hygiene, introduction, and allergy checks.
Integrate vital signs into the A to E assessment rather than treating them separately.
Prioritize airway issues before disability issues.
During disability assessment, perform a full GCS (eye response, verbal response, motor response, pupils' reaction to light, and limb strength) instead of the AVPU scale.
Document all observations on the GCS chart (NEWS2 chart is not used).
Verbalize the monitoring and escalation plan based on the patient's GCS score.
Complete the holistic assessment and conclude the station professionally.

Continue A to E assessment.
Monitor and record vital signs.
Perform and verbalize GCS monitoring.
- If GCS is 14 or less, monitor every 30 minutes until it reaches 15.
- If GCS is 15 with a history of head injury, monitor half-hourly for 2 hours, then hourly for 4 hours, and then hourly thereafter, according to NICE guidelines.

GCS monitoring to detect neurological deterioration.
History of falls, including frequency, causes, and use of mobility aids, to determine the need for physiotherapy or occupational therapy referrals.
Pain assessment to understand the level and nature of the headache.
Fluid input and output monitoring to assess dehydration risk, especially if the patient is vomiting or nil by mouth in preparation for surgery.

Psychosocial:
- Evaluate living situation and home accessibility.
- Assess available support services and family involvement.
- Evaluate emotional well-being.
- Ensure constant reassurance and reorientation for confused patients.
- Contact relatives as needed.
Spiritual and Sexual:
- Briefly address spiritual and cultural needs in the hospital.
- Inquire about support networks, including partners, marital status, and recent bereavements.

Aim: Reduce the risk of further deterioration and promptly identify changes in GCS.
Time Frame: Every 30 minutes if GCS is 14.
Interventions:
- Explain the plan of care and obtain consent.
- Monitor vital signs to detect signs of increased intracranial pressure.
- Assess and record GCS every 30 minutes until it reaches 15.
- Assess for signs of worsening hemorrhage, such as increased headache, confusion, neurological deficits, or one-sided weakness.
- Administer prescribed medications, including reversal agents for anticoagulants if applicable.
- Position the patient at a 30-degree head-up angle to promote venous drainage and reduce intracranial pressure.
- Support, reassure, and reorientate the patient.
- Document all care provided.

Analgesics:
- Paracetamol.
- Codeine phosphate is contraindicated in head injuries due to its potential to reduce alertness; it can break down into morphine.
Antiemetics:
- Cyclizine.
- Metoclopramide.
NMC Scenario-Specific Medications:
- Furosemide (diuretic).
- Bisoprolol (beta blocker).
- Atenolol (antihypertensive).
- Administer with caution due to potential for marked drop in blood pressure and subsequent brain ischemia.
Other Possible Medications (Awareness Only):
- Warfarin (anticoagulant): Should be withheld in acute bleeding.
- Vitamin K and Beriplex: May be used to reverse anticoagulation; verbalize if already administered.

Evaluate the patient's current state, typically improved with a GCS of 15, for handover or transfer to a ward.

Continue to assess GCS, adjusting monitoring frequency based on the patient's status (every 30 minutes for 2 hours, then every hour for 4 hours, and then every 2 hours if GCS is 15).
Continue to monitor and record vital signs.
Continue to assess headache and administer analgesics as prescribed.
Continue to monitor fluid input and output.
Follow up on referrals to physiotherapy or occupational therapy.
Promote safe mobilization and implement measures to reduce the risk of falls.