Elderly/alcoholic, gradual decline; crescent (concave) on CT, crosses sutures
ABCDE
A-B-C, protect airway if GCS≤8; reverse anticoagulation; urgent CT + neurosurgery.
First: Head CT without contrast; repeat neuro exam while awaiting report
Treat: Reverse anticoagulation → neurosurgical evacuation if large/symptomatic
Order set
- Non-contrast CT head
- Coags + reversal
- Neuro obs
- Neurosurgery referral
Criteria
AdmitAll with haematoma
ICU↓GCS, mass effect, post-evacuation
IntubateGCS ≤8 / deterioration
DischargeNeurologically stable, anticoagulation addressed, surgical decision made
Key
- Epidural = lens-shaped, arterial (middle meningeal), lucid interval — surgical emergency.
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- ↓GCS
- Pupil asymmetry
- Midline shift
Differentials
- Extradural haematoma
- Contusion
- Ischaemic stroke
Common mistakes
- Missing anticoagulation reversal
- Discharging elderly with subtle decline
Disposition & follow-up
Evacuation if large/symptomatic; reverse anticoagulation.
Discharge package
MedicationsReview/adjust anticoagulation plan
Follow-upNeurosurgery; repeat imaging as advised
Warning symptomsHeadache, drowsiness, vomiting, weakness
💊 Treatment detail — doses & preparation
Vitamin K (phytomenadione)warfarin reversal
DoseMajor bleed: 5–10 mg slow IV + PCC 25–50 U/kg; non-urgent: 1–3 mg PO/IV
Preparation10 mg/mL ampoule in 50 mL D5W over 20–30 min (anaphylaxis if fast)
MonitorINR at 4–6 h; re-warfarinisation window
PCC (4-factor)rapid anticoagulation reversal
Dose25–50 U/kg IV (warfarin major bleed/ICH)
PreparationReconstitute per vial, infuse 3–5 U/min
MonitorINR post-dose, thrombosis risk; combine with vitamin K
Mannitol 20%osmotic diuretic (ICP)
Dose0.25–1 g/kg IV bolus over 10–20 min for ICP crisis
Preparation20% (200 mg/mL) 500 mL bag via filter needle (crystals); may repeat q6–8h
MonitorSerum osmolality (keep <320), Na⁺, volume; effect wanes after 48 h
Levetiracetamantiepileptic
DoseStatus: 60 mg/kg IV (max 4500 mg) over 15 min; maintenance 500–1500 mg BD
Preparation500 mg/5 mL vial in 100 mL NS over 15 min; PO tablets/solution 1:1 conversion
MonitorMood/behaviour changes; minimal interactions
📖 Brain Trauma Foundation / NICE Head InjuryReviewed July 2026