Reliability in Catching Subdural Hematomas in the ED

[Chris07]

How reliably can a Subdural Hematoma be caught in the emergency department within a few hours of an incident? Does a slow bleed like that really show any signs early on?

Say you have an elderly person who hit the back of their head on the wall on the way down. Now to my understanding a much faster bleed would present symptoms within the first few hours. However, a slower bleed like a Subdural can take over 24 hours to start showing signs and other symptomology.

Can a standard CT reliably detect a small bleed only a few hours (< 6 hours) after the incident? Are there other diagnostic methodologies to rule out a bleed when no signs/symtpoms are present? Or is there really no true de-facto way to rule it out other than close monitoring of their condition for an extended period of time?

 

[JPINFV]

Subdurals should be easy to detect via CT. Subarachnoids, on the other hand...

 

[Ewok Jerky]

I would hope that in the setting of trauma a subdural would not be missed. However, a very small venous subdural would build slowly and might be missed shortly after the event. In that case it would probably not be clinically evident either. A repeat CT head in 24 hours woukd be reasonable if the patient showed Neuro symptoms. CT is gold standard for Dx, no other great modalities. I don't know what context you are in, but absent Neuro defecits and normal head CT = (pretty confident) no subdural

 

[medicsb]

As far as I know, no imaging technique has 100% sensitivity and specificity for anything. MRI is considered to be sensitive and specific for detecting subdural bleeds (not at all the standard of care in the ED). Anyhow, if a bleed is too small to be seen and the patient has a non-focal exam, does it really matter? Even when there is a known bleed, neurosurgery is typically adamant that reimaging NOT be performed unless there is change in mentation or a new neuro exam finding.

 

[JPINFV]

Emergency department MRIs are almost as rare as unicorns.

 

[samiam]

A common epidural bleed can come from a blow to the temple area of the head with a momentary loc. Ie if he has pain on the side of the head and passed out but is awake now be sure to transport.

On ct's a epidural strips the dura and forms a concave half circle. A subdural is going to be a longer more crescent like shape and a sub arachnoid is going to show blood in the sulci.

If you ever come upon a car accident and patient presents with pulsating eyes (pulsating exophthalmos) board and go. Likely to have sheared the internal carotid at the cavernosus sinus.

 

[Teddy KGB]

If I recall correctly CT catches 95%.

 

[Brandon O]

Big ups for pulsating exophthalmos, sir.