Head Trauma — Subdural HematomaEmergency

Neurology · Ward Pathways · Locked — free with a referral

By Dr Javed Akhtar · Last reviewed 2 October 2026

Presentation

78-year-old on apixaban for AF; fall 3 weeks ago; now increasing confusion, headache and right-hand clumsiness; CT: left crescentic mixed-density subdural collection, 6 mm midline shift

Red flags

GCS falling
Pupil asymmetry
Midline shift >5 mm
Anticoagulated with any intracranial blood

Differential diagnosis

Extradural haematoma
Contusion / intracerebral haemorrhage
Ischaemic stroke
Delirium from other causes
Tumour

When to admit, call ICU or discharge

Admit: All with symptomatic subdural haematoma or on anticoagulants with intracranial blood
ICU: GCS ≤8, falling GCS, after craniotomy
Intubate: GCS ≤8, airway compromise, uncontrolled seizures

Key points

Chronic SDH presents weeks after a trivial fall — confusion, headache, falls and hemiparesis in the elderly; "stroke" that fluctuates.
Extradural haematoma is lens-shaped (arterial, lucid interval) — a surgical emergency.
Tranexamic acid and atorvastatin do not reliably reduce chronic SDH recurrence; MMA embolisation does.

Never

Delay anticoagulant reversal for the neurosurgical opinion
Give dexamethasone for chronic SDH (worse outcomes — Dex-CSDH)
Transfuse platelets routinely for antiplatelet users without surgery
Discharge an elderly anticoagulated patient with a head injury without CT

Common mistakes

Not reversing anticoagulation
Discharging subtle decline in the elderly
Steroids
Restarting anticoagulation too early

Disposition and follow-up

Neurosurgical ward/HDU; ICU after major craniotomy or GCS ≤8. Falls prevention and anticoagulation review before discharge.

Locked

ABCDE first moves
The step-by-step decision sequence
Order set
Monitoring timeline and escalation triggers
Treatment doses and preparation
Discharge package

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