What should be included in the physical exam for suspected subdural hematoma (SDH)?

Updated: Jul 26, 2018
  • Author: Richard J Meagher, MD; Chief Editor: Helmi L Lutsep, MD  more...
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Physical examination of patients with head trauma should emphasize assessment of neurologic status using the Glasgow Coma Scale (GCS). The initial neurologic examination provides an important baseline that should be used to follow the patient's clinical course. When recorded in the form of the GCS score, it also provides important prognostic information.

Patients with serious head injuries often are intubated quickly and given trauma-oriented care. However, because of its prognostic significance, a brief neurologic examination quantified by using the GCS is an essential component of the secondary assessment and takes less than 2 minutes to complete. The GCS focuses on the patient's ability to produce intelligible speech, open the eyes, and follow commands. During the initial evaluation, the patient should be assessed for the ability to open the eyes spontaneously or in response to voice or to pain.

The patient's speech and mentation should be characterized as oriented, confused, inappropriate, incomprehensible, or none. The patient's motor function is determined by the patient's ability to follow commands on both the left and right sides. If the patient is unable to follow commands, note his or her ability to localize painful stimuli or to exhibit normal flexion on either side in response to the pain.

Decorticate and decerebrate posturing or lack of any motor function should also be recorded. Assess the size and reactivity of both pupils. Signs of external trauma should alert the physician to the expected location of coup or contrecoup injuries on CT scan.

A GCS score less than 15 after blunt head trauma in a patient with no intoxicating substance use (or impaired mental status baseline) warrants consideration of an urgent CT scan. Search for any focal neurologic deficits or signs of increased ICP. Any abnormality of mental status that cannot be explained completely by alcohol intoxication or the presence of another mind-altering substance should increase suspicion of subdural hematoma in the patient with blunt head trauma.

The presence of a focal neurologic sign following blunt head trauma is ominous and requires an emergent explanation. Patients with possible subdural hematoma should be examined for related injuries (using guidelines established by the American College of Surgeons Committee on Trauma), such as cervical spine fracture, spinal cord injury, or long-bone fractures.

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