Resuscitation (Ig72), x, 201-204

Complete recovery a&r resuscitation and emergency cramotomy in three children with acute epidural haematoma

JAVIER VERDURA, SAMUEL RESNIKOFF, JUAN CARDENAS, ALEJANDRO DE AVILA and JAIME ROSENTHAL

Department of Surgery, Sections of .Neurosurgery and Amaesthka, American British Cowdray Hospital, Mexico CiQ, Mexico

Successful surgical treatment of acute epidural haematoma after resuscitation in three children is reported. The importance of accurate diagnosis and appropriate resusci- tative and neurosurgical procedures is stressed.

Introduction

Unconscious patients surviving decerebrate rigidity and fixed dilated pupils have been the subject of several reports in the literature (Campbell & Cohen, 1951; Freedman, 1952 ; Brendler & Silverstone, 1970). Although there have been reports of emergency craniotomies (see, for example, Alexander, I 962) there is little literature on resuscitation of children before surgical removal of an acute epidural haematoma. This communication reports three cases of children with acute epidural haematoma, who had to be resuscitated before emergency surgery at the American British Cowdray Hospital.

Case histories

Case I A 7 year old boy was admitted to the emergency ward on 25th November, xgsS

at 3.00 p.m., with a history of having fallen from a bicycle at 12.00 noon on the same day. When he fell, he had been dazed but not unconscious. He had vomited once and complained of right-sided headache. On admission, he had no neurological signs, and an X-ray showed no fracture. He was sent home, with instructions to his parents to observe him closely, particularly in respect of his state of consciousness. At 7.00 p.m. on the same day, the child was brought back to the hospital completely comatose; he had bilateral decerebrate rigidity, the right pupil was fixed and dilated, the heart rate was &/min and irregular, the respirations were shallow at a rate of r2/min and the blood pressure was go/50 mm mercury. By 7.20 p.m. he had had a respiratory arrest and an endotracheal tube had been inserted and connected to an automatic ventilator; both pupils were fixed and dilated, with the right pupil still

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202 J. VERDURA, 5. RESNIKOFF, J. GARDENAS, A. DE AVILA AND J. ROSENTHAL

being larger; the pulse was 24/min and no blood pressure could be recorded; he had already been started on intravenous 20% mannitol. As the pulse could not be detected, external cardiac massage was started. A temporoparietal flap was turned, without anaesthesia (and before shaving could be completed), and a 200 g epidural haematoma was evacuated.

The pulse started almost immediately, at 6o/min, and the blood pressure rose to 80150 mm mercury. The surgeon then proceeded with a normal craniotomy. One hour after the evacuation of the haematoma, the blood pressure was 100/6o mm mercury. The heart rate was 12olmin and the child was breathing spontaneously at a rate of 3o/min. The left pupil was 3 mm in diameter and responded to light; the right pupil remained fixed and dilated. After surgery, the patient was placed on steroids and large doses of antibiotics were given intravenously. He remained un- responsive for the next 24 h, but later he made a complete recovery with no neuro- logical deficit, and was not subject to an infection.

Case 2

A 14 year old boy was admitted to the emergency ward on 19th February, rg6g with a history of having been struck by a fast-moving car. He had been unconscious for 30 min, but later he recovered consciousness and was able to walk and talk. During the next 4-5 h, he became stuporose, he lost his speech and his right side was weak. On neurological examination he had a right hemiparesis, facial weakness of central original, mixed aphasia and a positive Babinski sign. His pulse rate was 6o/min the blood pressure 180/100 mm mercury, and the respiratory rate 24/n+.

X-ray of the skull showed a left temporal fracture (Plate IA), and a left carotid arteriogram demonstrated an epidural collection of fluid (Plate I B). An endotracheal tube was inserted, and a left parieto-temporal craniotomy was carried out under Fluothane anaesthesia.

Fifteen minutes after the skin incision the anaesthetist reported that the heart sounds could no longer be detected; the electrocardiogram showed fibrillation, and the blood pressure was unobtainable. The patient’s chest was exposed, the heart externally defibrillated, and external cardiac massage instituted. The bone flap was then turned extremely rapidly, and a 150 g epidural haematoma was removed. Three minutes later, the heart sounds tiere heard again, and sinus rhythm could be seen on the cardioscope at a rate of go/min and the blood pressure rose to 100/50 mm mercury. At the end of the operation, the clinical signs were within normal limits and the child was breathing spontaneously. His post-operative course was complicated by a blood transfusion reaction, but otherwise he made an uneventful recovery without neurological deficit.

Case 3 A 3 year old boy fell off his tricycle on 12th August, rg7o at 3.00 p.m., striking his

head against a cement floor; he was unconscious for about 3 min, but later became alert and continued to play. At 5.00 p.m. a paediatrician was called because the boy had vomited; X-ray of the skull showed a linear transverse fracture of the right parietal bone (Fig. 3). The child was therefore admitted to the American British Cowdray Hospital at 6.00 p.m. on the same day. At that time he was alert but some- what drowsy, and had vomited several times; his pulse was 68/min, the blood

(b)

Plate I. (0) Lateral X-rayofskull in case 1, demonstrating a temporal linear fracture. (b) X-ray ’ of a left carotid arteriogram in case 2: showing an epidural collection of blood.

Anteropostc :rior

Plate 2. Lateral X-ray of skull film in case 3, depicting a linear fracture across the parietal region.

RESUSO~~AT~ONFROMEPIDURAL HAEM.~TO~ 203

pressure 140/70 mm mercury and the respirations were r8/min. The neurological examination was reported as negative. On examination at 8.00 p.m. he was found to be comatose, with bilateral decerebrate rigidity and a right fixed dilated pupil. He was carried down to the operating room, and while his head was being shaved, cardiorespiratory arrest developed; he was immediately intubated and respired manu- ally while external cardiac massage was instituted. Both pupils were dilated at that time.

Without anaesthesia, a right temporo-parietal burr hole was made and enlarged with bone rongeurs, allowing the evacuation of a large epidural haematoma. Soon after this decompression the heart began to beat spontaneously at a rate of ~oo/min and the blood pressure became audible on phonocardiography. A right temporo- parietal craniotomy was then carried out. Two hours after the cardiac arrest his pulse was 12o/min, blood pressure I 10/6o mm mercury and he was breathing at a rate of 26/min.

Discussion

The three patients described here were classical cases of epidural haematoma, with a ‘lucid’ interval. Three exhibited cardiorespiratory arrest; two had decerebrate rigidity and bilateral dilated pupils. All three survived without neurological sequelae, probably because of their age group (Campbell & Cohen, 195 I), their lack of associ- ated brain injury and the rapidity with which resuscitative manoeuvres and surgery were instituted (Jamieson & Yelland, I 968).

It has generally been thought that the prognosis of the condition in which neuro- logical deterioration follows a lucid interval is favourable (McLaurin & Ford, 1964; Hawkes & Ogle, 1962). However, it has been pointed out that when cerebral decompensation occurs, it may be quite sudden, for example, while the operating theatre is being prepared. Matson (1962) noted that a baby with no neurological signs may suddenly go into profound coma, with a dilated pupil, respiratory distress and cardiac arrhythmia. Alexander (1962) sometimes made a burr hole without waiting to shave the head to evacuate a haematoma in apnoea with a dilated pupil.

Gallagher & Browder (1968) analysed I 76 patients with extradural haematoma, and found bradycardia of less than 6o/min in 50% of their cases; in one patient heart rate was only 25/n&. Of 47 patients with proven epidural haematoma only seven exhibited decerebrate rigidity before surgery, and only one had changes in blood pressure, pulse and respiration serious enough to warrant surgical intervention. In 25 other patients without cerebral continusion, two who had bilaterally fixed pupils and decerebrate posture both died.

References

Alexander, E. Quoted in Hawkes ct al. (I 962) 3. Ncurosarg. rg, g7 r-g8o Brendler, J. S. & Silverstone, B. (1970) Recovery from decerebration. Brain. 98, 881-892 Campbell, J. B. & Cohen, J. (1951) Epidural hemorrhage and the skull of children. Surg. Gyaec.

Obsict. gz, 257180 Freedman, H. (1952) Recovery from the decerebrate state associated with supratentorial space-taking

lesions. 3. Narosurg. g, 52-28 Gallagher, J. P. & Browder, E. J. (1g68) Extradural hematoma. 3. Jvcurosurg. ag, 1-12 Hawkes, C. D. & Ogle, W. S. (I g62) A typical features of epidural hematoma in infants, children and

adolescents. 3. Ncurosurg. rg, 971-980

204 J. VERDURA, 5. RESNIKOFF, J. ChDENAS, A. DE AVILA AND J. ROSENTHAL

Jamiaon, K. G. & Yelland, J. D. N. (I@) Extra&al hematoma. J. Xmosurg. 2g, 13-m Matson, D. D. Qyotcd in Hawked et al. (x962) J. .hhtmrg. 1% 7cg8o McLaurin, R. L. & Ford, L. E. (1964) Extradural hcmatoma. tatiatical survey of forty-seven cases. 8

3. N-g. -9 364-371