Unsteady Refusal - SDH

Unsteady Refusal - SDH


A stubborn refusal but persistent EMS,  yields discovery of a subdural hematoma

Dr. Donald Spaner

Case Summary:

EMS arrives in Metro Park walking trail to find an 80-year-old male who had fallen and struck his head.  He seems unsteady and does not want to go to the hospital.  EMS asks simple orientation questions, and he is confused to the day.  He agrees to go into the squad for evaluation but is refusing transportation.  His vitals are 170/100, pulse 65, respirations 18 and pulse ox is 96%.  The providers again request that he be evaluated.  Without explanation he simply responds, "I'm not going".

Question: What would you do?

EMS understanding that he is not demonstrating the capacity to refuse care, they go the extra step and call his wife.  She speaks to him and realizes he is not acting himself.  She talks him into going to the hospital.  The emergency department found on the CT scan a large subdural hematoma requiring emergency neurosurgical evacuation.  The patient did well, because the EMS providers recognized this patient lacked the capacity to refuse.  Their care and concern is in keeping with the highest standards of pre-hospital care, and this patient can spend many more years with his wife, thanks to the care he received.

Surgery is recommended for most subdural hematomas. Very small subdural hematomas may be carefully monitored first to see if they heal without having an operation.

If surgery is recommended, it'll be carried out by a neurosurgeon (an expert in surgery of the brain and nervous system).

There are 2 widely used surgical techniques to treat subdural haematomas:

Craniotomy – a section of the skull is temporarily removed so the surgeon can access and remove the hematoma.

Burr holes – a small hole is drilled into the skull and a tube is inserted through the hole to help drain the hematoma.


A craniotomy is the main treatment for subdural hematomas that develop soon after a severe head injury, (acute subdural hematomas).

During the procedure, the surgeon creates a temporary flap in the skull. The hematoma is gently removed using suction and irrigation, where it's washed away with fluid.

After the procedure, the section of skull is put back in place and secured using metal plates or screws.

This is usually performed under a general anesthesia.

Burr holes

Burr hole surgery is the main treatment for subdural hematomas that develop a few days or weeks after a minor head injury, (chronic subdural hematomas).

During the procedure, one or more small holes are drilled in the skull and a flexible rubber tube is inserted to drain the hematoma.

Sometimes the tube may be left in place for a few days afterwards to drain away any blood and reduce the chances of the hematoma coming back.

Burr hole surgery is often carried out under general anesthetic but is sometimes done under local anesthetic.

This means you remain awake during the procedure, but the scalp is numbed so you do not feel any pain.

Recovering from surgery

If surgery goes well and you do not have any complications, you may be well enough to leave hospital after a few days.

If you do develop complications, it may be several weeks before you're able to go home.

If you have persistent problems after surgery, such as memory problems or weakness in your limbs, you may need further treatment to help you gradually return to your normal activities.

The length of time it takes to recover from a subdural hematoma will vary from person to person.

Some people will feel a lot better after a few weeks, while others may never make a full recovery.