A patient comes to the emergency department with a history of a head injury and a brief period of unconsciousness followed by a lucid interval and then a rapid decline in level of consciousness. The nurse suspects the client has which type of hematoma?

A subdural hematoma and an epidural hematoma differ in origin, location, and presentation. An epidural hematoma usually results from arterial bleeding between the dura mater and the skull, while a subdural hematoma results from venous bleeding between the dura mater and the arachnoid space. Subdural hematomas are especially common in older adults because brain atrophy stretches and weakens the bridging veins.

Rationale for correct answers:
1. An epidural hematoma is typically arterial in origin, while a subdural hematoma is usually venous. This distinction is important because arterial bleeding causes rapid deterioration, while venous bleeding tends to progress more gradually.
2. An epidural hematoma is located between the dura mater and the skull. This position allows blood to accumulate quickly and compress brain tissue, leading to sudden neurological decline.
4. A subdural hematoma is located between the dura mater and the arachnoid space. Because of its venous origin, this bleeding can expand slowly and symptoms may appear hours to weeks after injury.
6. Subdural hematomas are more common in older adults due to brain atrophy. The shrinkage of brain tissue places tension on veins, making them more vulnerable to rupture from minor trauma.

Rationale for incorrect answers:
3. A subdural hematoma is often associated with a brief lucid interval. The lucid interval is a classic sign of epidural hematoma, not subdural.
5. An epidural hematoma is a slow bleed, whereas a subdural hematoma is a rapid bleed. This statement is incorrect because epidural hematomas develop quickly due to arterial bleeding, while subdural hematomas develop more slowly due to venous bleeding.

Take-home points:

• An epidural hematoma involves arterial bleeding, located between the dura mater and the skull, and often progresses rapidly with a lucid interval.
• A subdural hematoma involves venous bleeding, located between the dura mater and the arachnoid space, and usually develops more gradually.
• Subdural hematomas are frequently seen in older adults because brain atrophy stretches the veins.
• Recognizing these differences helps guide early diagnosis and treatment.

Clear fluid drainage from the nose (possible cerebrospinal fluid leak) and raccoon eyes (periorbital ecchymosis) are classic signs of a basilar skull fracture, which involves the base of the skull. These findings indicate a potential dural tear and increased risk for meningitis due to CSF leakage.

Rationale for correct answer:
3. Basilar skull fracture. Basilar skull fractures commonly present with CSF rhinorrhea or otorrhea, raccoon eyes, or Battle’s sign (bruising behind the ears). These findings are hallmark indicators of this type of fracture.

Rationale for incorrect answers:
1. Depressed skull fracture. Involves bone fragments pressing inward, often seen with localized injury or lacerations, not typically with raccoon eyes or CSF leakage.
2. Linear skull fracture. A simple break in the bone without displacement. It usually does not produce obvious external signs like raccoon eyes or CSF drainage.
4. Compound skull fracture. Involves a break in the skin and skull bone exposure, increasing infection risk, but is not classically associated with raccoon eyes or CSF rhinorrhea.

Take-home points:

• Basilar skull fracture = raccoon eyes, Battle’s sign, CSF leakage.
• Always test drainage for CSF (halo sign or glucose testing) to confirm.
• High infection risk → monitor closely for meningitis.
• Avoid nasogastric tube insertion in suspected basilar fractures to prevent intracranial placement.