1. Vacca, Vincent M. Jr. RN, CCRN, MSN

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ACCOMPANIED BY his coach, Jon Mobley, 24, is brought to the ED by ambulance after being hit in the head by a fastball during a community baseball game. He's wearing a cervical collar. The emergency medical personnel report that when they arrived on the scene, Mr. Mobley was awake, alert, and oriented and complaining of a headache, but had no other signs or symptoms of neurologic injury.


What's the situation?

Although Mr. Mobley was wearing a batting helmet, he was struck in the left temporal region and briefly lost consciousness, according to the baseball coach. His airway is patent and his vital signs are stable and within normal limits, but he's drowsy and he says his headache is worsening. He's unclear about details preceding his arrival in the ED. When you reassess his neurologic status, you find that his left pupil is larger than the right (4 mm versus 3 mm) and is sluggish in response to light. His right arm is noticeably weaker than his left and exhibits pronator drift (that is, it drifts downward and may pronate when he extends both arms in front of him, palms up, with his eyes closed).


What's your assessment?

Based on Mr. Mobley's history, injury, and signs and symptoms, you suspect an epidural hemorrhage with enlarging hematoma. You immediately discuss your findings and concerns with the ED physician.


The thinnest and weakest area of bone in the skull is the temporal region; the middle meningeal artery is located immediately behind it. A blunt force impact to this area of the head can result in a skull fracture and laceration of the middle meningeal artery. Bleeding from the middle meningeal artery strips the dural membrane away from the skull, forming a hematoma between the dura mater and the skull. The hematoma in turn causes increased intracranial pressure and displacement of brain tissue. You'll see decreased level of consciousness, confusion, headache, ipsilateral pupillary dilation, and contralateral hemiparesis, demonstrated by his right pronator drift. Mr. Mobley has all these signs and symptoms, as well as a brief episode of decreased consciousness or loss of consciousness at the time of injury, followed by a temporary lucid period.


Quick recognition and treatment is crucial because an expanding epidural hematoma puts Mr. Mobley at risk for seizures, coma, irreversible neurologic damage, and temporal lobe or uncal herniation that can lead to brainstem compression and death.


What must you do immediately?

The ED physician orders a stat noncontrast head computed tomography (CT) scan, which will show the location and volume of blood from the injury and other injuries if present. Mr. Mobley has no cervical spine injuries, so you elevate the head of the bed 30 degrees to help reduce intracranial pressure. While arrangements for the CT scan are being made, update Mr. Mobley on what's happening, administer supplemental oxygen and monitor his SpO2, establish I.V. access, put Mr. Mobley on a cardiac monitor, and send samples for lab studies. The coach has called Mr. Mobley's wife, who's on her way to the hospital. The CT scan reveals a temporal bone fracture with an epidural hemorrhage and hematoma causing brain tissue shift.


Mr. Mobley undergoes immediate surgical evacuation of the hematoma and repair of the lacerated middle meningeal artery. Because Mr. Mobley was diagnosed and treated quickly, he has no permanent brain damage and an excellent prognosis.


What should be done later?

Mr. Mobley is transferred to the neurologic ICU for postoperative management. He makes a rapid and uneventful recovery and is transferred the next day to the neurologic intermediate care unit for further care and discharge teaching. Three days later, Mr. Mobley is discharged home with follow-up arrangements.