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05.02 Intracranial Hemorrhage

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Overview

I. While subdural and epidural hematomas are both injuries involving bleeding on the brain, their presentation, and subsequent treatment can be significantly different.

Nursing Points

General

  1. Presentation
    1. How to tell difference between a subdural and epidural bleed with initial presentation
    2. Urgency for each
  2. Likely ER interventions or what the nurse should anticipate
    1. Ex: subdural may just get CT and monitoring if small, epidural may go straight to OR for evacuation/cautery

Assessment

  1. Subdural Bleed
    1. Headache
    2. Progressive loss of conciousness
    3. Fixed and Dilated (first one then both)
    4. Abnormal Resps
    5. Contralateral hemiparesis
    6. Increased ICP
    7. N/V
  2. Epidural Bleed
    1. Severe Headache
    2. Agitation
    3. Sudden of progressive loss of conciousness
    4. Lights out! –> Lights on! –> Lights out!
    5. One dilated pupil
    6. Contralateral weakness
    7. Bradycardia
    8. Increased BP
    9. Abnormal Resps
  3. For both
    1. Serial neuro exams – GCS
    2. Monitor ABCS
    3. Monitor ICP with GCS of 8 or less and abnormal CT

Therapeutic Management

  1. For both:
    1. Serial neuro exams – GCS
      1. Less than 8 – intubate
    2. Maintain O2 sat greater than 95%
      1. Avoid hyperventilation
    3. Restore fluid volume as needed
      1. Foley Cath (0.5 to 1 mL/Kg an hour)
    4. CT scan
    5. Monior ICP with GCS of 8 or less and an abnormal CT
      1. Reduce ICP if needed
    6. Facilitate surgical intervention
  2. Subdural Bleed
    1. Surgical evacuation or burr holes with gradual drainiage
  3. Epidural Bleed
    1. Emergent surgical evacuation

Nursing Concepts

  1. Anatomy and Physiology
  2. Cognition
  3. Intracranial Regulation

Patient Education

  1. Identifying signs of head injury
  2. Get the victim to a hospital, time is of the essence

Reference Links

Video Transcript

Greetings everyone and welcome to our lesson on Intracranial Hemorrhage. Specifically, we are going to discuss the differences in presentation and treatment in the emergency department for subdural and epidural bleeds.

So the definitive treatment for these injuries is significantly different. that being the case, it is very important to recognize some very telling signs and symptoms that will help us decide which injury our patient has sustained.

When it comes to presentation, there some subtle differences between the two, and there are some glaring differences…so let’s go through them

With our subdural bleed, our patient will most likely have a headache and this can be a simple annoying headache or one that is causing them a lot of pain. What we want to know, is how long they have been feeling this. The concept of acute vs chronic bleed comes into play with subdural (and you can read much more about that in our neuro lessons throughout NRSNG.com)

They will have a slow, progressive decrease in their level of consciousness. many complain of being overly tired.

Pupils… they will be fixed and dilated. First unilaterally, meaning only one side, but as the bleeding progresses it will be bilateral.

The respirations will be abnormal, and this could be hyper or hypoventilation

They can experience contralateral hemiparesis… one-sided weakness or paralysis

Most likely they will have an increase in their intracranial pressure and many times they will experience nausea and vomiting.

With our epidural bleed, the headache is going to be severe, some have reported feeling like a gunshot went off in their brain, or like they got stabbed in the head with an icepick.

They can be agitated and they might have a sudden loss of consciousness or a progressive one.

Lights out, lights on, lights out. This is a very telltale sign of an epidural bleed. Usually sustained from trauma, the patient will have an instant loss of consciousness, followed soon after by a period of awakened lucidity, which will then be followed by another loss of consciousness. If this is reported to you… it should send up a ton of red flags!

The pupils here will be unilaterally dilated.

They will also have that contralateral weakness

And as far as the vital signs go, we might see bradycardia, hypertension and abnormal respirations.

When we are assessing these patients, many of the assessments are the same.

We want to do our serial neuro exams, probably every 5 to 15 minutes…check your facilities policy. And what we are looking at is the GCS. Motor Response, Eye-opening, and verbal response. Remember…the scale goes from 3-15..not 0-15.

As with any of our patients, we want to monitor our Airway, breathing, and circulation

And if our patients have a GCS of 8 or less and a funky CT scan, we are probably going to monitor their intracranial pressure with an ICP monitor, most likely inserted right in the ED.

Now we have to manage these patients, right?

Well if the GCS is less than 8, it is usually assumed they are going to have trouble maintaining their own airway, so we are going to intubate and ventilate them.

We want to keep that oxygen level above 95Z% to make sure the brain is perfusing and we are getting the O2 where it needs to be. Be careful if we are bagging the patient with a BVM, or bag valve mask, that we do not hyperventilate them. Why would that be bad to give them more oxygen Nurse Mike? You just told us the brain needs oxygen. I’m glad you asked. While oxygen is of course vitally important to brain health,  hyperventilation can actually cause an increase in ICP, so clearly we want to be careful.

We are going to restore fluid volume as needed and the way we are going to monitor this is by inserting a urinary catheter and keeping an eye on output. we want 0.5 to 1 ml/kg an hour and we can adjust our fluid infusion rates accordingly.

If we have that patient with a GCS of less than 8 who s intubated and has that ICP monitor, we will want to reduce the ICP if needed. Whether we do that with medications like Mannitol or through physical interventions like positioning or decreasing stimulus will depend on the situation and the actual ICP level. 

With subdural bleeds, we have to act, but we can be a little more meticulous with it. These patients will take a nice east ride to the OR where we will place some small burr holes to allow for gradual drainage of the fluid building up. My hope is that most of us work in a facility that will be a little more sterile than the one in that picture here. But I have to say, I do love the hat the surgeon is wearing. I’m not quite sure what the nun is doing with the book on her head. I tried that in the OR once and it did not help the situation.

With an epidural bleed, the patient will probably undergo a craniotomy, or the removal of a piece of the skull to allow for a fast decrease in ICP. You can see in the picture here that a flap of the skull has been removed and we can see the brain underneath. 

I highly recommend you guys go review the neuro lessons around the site to learn where and why subdural and epidural bleeds occur. 

It’s important to evaluate our patient’s cognition throughout their stay in the ED, using our neuro exams and our GCS  

and if needed, we want to watch that ICP and treat it accordingly.

I highly recommend you guys go review the neuro lessons around the site to learn where and why subdural and epidural bleeds occur. 

It’s important to evaluate our patient’s cognition throughout their stay in the ED, using our neuro exams and our GCS and if needed, we want to watch that ICP and treat it accordingly.

OK guys, so that’s a little bit about what we do for subdural and epidural bleeds in the emergency department. join us for our next emergency topic and as always…

HAPPY NURSING!!!

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