Running head: subdural hematoma 1 Krista Chapin

Running head: SUBDURAL HEMATOMA 1

Krista Chapin

Evidence Based Practice for Subdural Hematomas

USF College of Nursing

Evidence Based Practice for Subdural Hematomas

Through spending some time this semester in critical care, it is imperative that nurses conduct neurological assessments eat least every two hours. In the Neurological Intensive Care Unit (NICU), this is especially true. Patients admitted to the NICU often suffer from some type of brain injury as a result of a traumatic event. A common disease seen in the NICU are hematomas. Some patients may fully recover from this disease and some may never become conscious again. In this paper the Subdural Evacuating Port System (SEPS) will be discussed for patients who have been diagnosed with a subdural hematoma. SEPS is placed into the subdural layer of the brain. A tiny 2cm incision is made into the skull, and the periosteum is removed. A drill is used to create a durotomy, and this is where the port used for evacuation goes through. Once the hole is creating tubing is placed at the end of the evacuating port and low suction is attached to allow blood to drain from the subdural space. There are many benefits of this surgery which will be discussed throughout this paper. SEPS is a viable treatment option for patients suffering with a subdural hematoma.

Additionally, to better serve these patients it is important that the pathophysiology is fully understood by their nurse. According to Meagher, R. & Lutsep, H. (2013), subdural hematomas are usually caused by a high impact event; such as a traumatic brain injury or a motor vehicle accident. Less common etiologies of this disease include: arteriovenous malformations, coagulopathies, tumors, intracranial hypotension following a lumbar puncture, CSF leak, and epidural anesthesia. The high impact force of a traumatic brain injury or motor vehicle accident often results in ruptured blood vessels which connect to the cortical surface of the brain and then to a dural sinus. In the elderly, this may already be ruptured due to stretching because of brain atrophy associated with aging. Hematomas may also be caused by laceration or injury to a cortical vessel. This is most often seen in after a minor head injury such as a contusion. The bleeding within the brain causes an increase in intracranial pressure, intraparenchymal insults, or direct pressure and injury on the subdural layer of the brain.

The prognosis of an acute subdural hematoma ranges greatly from 36-79%. Many of those who do survive will never have the same level of functioning as they did prior to their injury. The prognosis also depends on the age of the patient. It has been shown that patient’s younger than 40 have a mortality rate of 20%, those from ages 40-80 have a mortality rate of 65%, and those older than 80 have a mortality rate of 88%.

The main treatment for these hematomas is surgery. An emergent craniotomy and surgical decompression is used to evacuate the hematoma. After the procedure an intracranial pressure monitor is usually placed inside the brain to monitor the levels and treat the patient’s blood pressure to ensure another hematoma does not occur.

Furthermore, the results from a study by Singla, Jacobsen, Yusupoy, & Carter (2013) show the need for a new treatment method. The most common treatment to evacuate blood from the brain is to perform a craniotomy and drill through the skull to evacuate the blood. This drill is inserted into dura and then into the membrane, once a hole has been created a drain is placed into the skull to allow for the excess blood to be drained. There are many inherent risks with such an invasive procedure. Patients have up to a 25% chance of developing a morbidity from the procedure, and up to an 11% chance of mortality. Patients who undergo this invasive surgery must be monitored very closely post operatively. It is the nurse’s responsibility is to notice and treat any changes in their neurological status. In the NICU at Bayfront Medical Center, nurses must complete a full neurological assessment at least every two hours. The nurses should also monitor lab values, and vital signs for any signs of infection, which is common in such a serious procedure. Due to all of the risks of this procedure there is a clear need for a better and less risky treatment.

A 97 year old patient was admitted into the NICU for a subdural hematoma after a fall. This patient had a craniotomy done to evacuate the blood from her brain after her level of consciousness deteriorated to the point where she required intubation. Once the procedure was performed this patient never woke up. The nurse in the NICU assessed her neurological status every two hours, gave her the medicines she was prescribed, turned her every two hours, and provided oral hygiene care. This women would have been a great candidate to undergo a SEPS. The utilization of SEPS could save many patient’s lives. According to Singla et al. (2013), 73% of patients improved after this procedure. It is an outpatient procedure and would greatly benefit elderly patients because this procedure is not as invasive as a craniotomy.

Kenning, Dalfino, German, Drazin, & Adamo (2010) found similar results. This procedure does not require general anesthesia, so it will benefit elderly patients. A craniotomy is a large procedure that does require general anesthesia. The 97 year old woman in the NICU could have certainly benefited from this procedure. There is a research gap in this field of neurology. This procedure has not been incorporated into Bayfront Medical Center, and it is a great option for the elderly population which makes up a large portion of Bayfront’s patients.

SEPS is a better alternative for elderly patients who require the evacuation of a subdural hematoma. There is a large amount of research currently being done on this procedure, but it is still not considered the gold standard. Health care professionals should familiarize themselves with this procedure because it is less invasive than a craniotomy (Kenning et al., 2010).

References

Kenning, T., Dalfino, J., German, J., Drazin, D., & Adamo, M. (2010). Analysis of the subdural evacuating port system for the treatment of subacute and chronic subdural hematomas. Journal of Neurosurgery, 113, 1110-1114. doi: 10.3171/2010.5.JNS1083.

Meagher, R., Lutsep, H. (2013). Subdural hematoma. Retrieved from

http://emedicine.medscape.com/article/1137207-overview#a0104

Singla, A., Jacobsen, W., Yusupov, I., & Carter, D. (2013). Subdural evacuating port system (SEPS)—minimally invasive approach to the management of chronic/subacute subdural hematomas. Clinical Neurology and Neurosurgery, 115, 425-431. Doi: http://dx.doi.org/10.1016/j.clineuro.2012.06.005