Understanding Subdural Hematoma ICD-10 Codes

A subdural hematoma (SDH) is a serious medical condition in which blood collects between the dura mater (the outer protective covering of the brain) and the brain itself. This can lead to increased pressure on the brain, causing neurological symptoms such as headaches, confusion, seizures, and loss of consciousness. Subdural hematomas can range from mild to life-threatening and may result from head trauma, coagulopathy, or other underlying conditions. 

What is a subdural hematoma? 

A subdural hematoma occurs when blood vessels, usually veins, rupture and bleed into the subdural space. This accumulation of blood puts pressure on the brain, potentially leading to brain injury or death if left untreated. Subdural hematomas can be categorized as acute, subacute, or chronic depending on the time frame of their development after injury and the severity of symptoms. 

• Acute subdural hematoma: Typically develops within 72 hours of a head injury and often presents as a medical emergency. 
• Subacute subdural hematoma: Develops within 3 to 7 days after an injury, with symptoms that may evolve more gradually. 
• Chronic subdural hematoma: Develops over weeks to months, often with subtle symptoms that can be mistaken for other conditions, especially in older adults. 

ICD-10 codes for subdural hematoma 

The ICD-10 coding system provides a range of codes for documenting the severity and type of subdural hematoma. These codes are essential for accurate diagnosis, treatment, and reimbursement purposes. 

S06.5X0A – Traumatic subdural hemorrhage without loss of consciousness, initial encounter 

Definition: This code applies to cases of traumatic subdural hematoma where the patient did not lose consciousness at the time of injury, and this is their first visit for the condition. 

Nursing application: For patients who present with a traumatic subdural hematoma but without loss of consciousness, nursing care focuses on monitoring for signs of neurological deterioration. Nurses should perform regular neurological assessments, including checking for changes in level of consciousness, pupil reactivity, motor strength, and speech. It’s also critical to monitor for the development of new symptoms such as headaches, vomiting, or changes in vision, which may indicate increased intracranial pressure (ICP). Patients should be educated about the potential delayed onset of symptoms, especially if they are discharged from the hospital. 

S06.5X9A – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, initial encounter 

Definition: This code refers to cases of traumatic subdural hematoma where the patient experienced a loss of consciousness, but the duration of unconsciousness is unspecified. This also applies to the first time the patient is being treated for the condition. 

Nursing application: Nursing care for patients with a traumatic subdural hematoma and loss of consciousness involves frequent and thorough neurological checks. Vital signs, particularly blood pressure, should be monitored closely to detect signs of increased ICP. Nurses should also manage the patient's airway and ensure oxygenation, as reduced brain perfusion can occur with elevated ICP. Administering medications such as mannitol or hypertonic saline to reduce brain swelling and preparing for possible surgical intervention (such as a craniotomy) may be necessary. Family and patient education on recovery and the need for follow-up brain imaging are also important. 

S06.5X0D – Traumatic subdural hemorrhage without loss of consciousness, subsequent encounter 

Definition: This code is used for follow-up encounters where the patient had a traumatic subdural hematoma without loss of consciousness during the initial incident. 

Nursing application: During follow-up visits, nurses should continue to assess for residual or recurring symptoms, such as headaches, dizziness, or cognitive difficulties. Education on gradual return to normal activities and avoidance of situations that could result in further head injuries is essential. Nurses should also help patients adhere to prescribed medications, such as anticoagulants (if they are at risk of clotting disorders) or anticonvulsants, which may be prescribed if seizures are a concern. 

S06.5X1A – Traumatic subdural hemorrhage with loss of consciousness for 30 minutes or less, initial encounter 

Definition: This code is used when a patient experiences a loss of consciousness (30 minutes or less) following a traumatic subdural hematoma, and this is their initial encounter for treatment. 

Nursing application: For patients with loss of consciousness following a subdural hematoma, the nursing care plan includes monitoring for changes in neurological status, such as confusion, agitation, or further altered mental status. Nurses should perform regular Glasgow Coma Scale (GCS) assessments to track the patient’s cognitive and motor responses. Education on the symptoms of brain swelling and when to seek urgent medical care after discharge is critical. 

S06.5X3A – Traumatic subdural hemorrhage with loss of consciousness of 1 to 5 hours, initial encounter 

Definition: This code is for patients who experienced a loss of consciousness between 1 and 5 hours after sustaining a traumatic subdural hematoma. These cases may be more severe, requiring close monitoring and possibly surgery. 

Nursing application: Nursing care for patients with extended loss of consciousness includes frequent assessment of neurological function and the maintenance of adequate cerebral perfusion. Patients may require intubation and mechanical ventilation if their consciousness does not return quickly. Nurses should prepare the patient for potential surgical intervention (such as a craniotomy or burr hole drainage) and provide support to families who may be distressed by the severity of the situation. Educating caregivers about the patient’s long-term rehabilitation process is important, as recovery may take months. 

S06.5X9D – Traumatic subdural hemorrhage with loss of consciousness of unspecified duration, subsequent encounter 

Definition: This code is used for follow-up visits after the initial encounter with traumatic subdural hematoma, where the patient had an unspecified duration of loss of consciousness. 

Nursing application: Follow-up nursing care focuses on rehabilitation and preventing complications. Nurses should assess for any residual cognitive or motor deficits and work closely with the rehabilitation team to implement physical, occupational, and speech therapies as needed. Additionally, patient and family education about the signs of secondary brain injury, such as seizures or personality changes, is crucial for ongoing care. 

Nursing interventions for subdural hematoma 

Managing a patient with a subdural hematoma requires a comprehensive nursing approach to monitor for complications, prevent further injury, and promote recovery. Here are key nursing interventions: 

1. Neurological assessment: Nurses must frequently assess the patient's neurological status, including their level of consciousness, orientation, motor responses, and pupil reactivity. The Glasgow Coma Scale (GCS) is a valuable tool for tracking changes in consciousness, which may indicate worsening intracranial pressure. 
2. Monitor intracranial pressure (ICP): Subdural hematomas can lead to increased ICP, which can be life-threatening. Nurses should watch for signs of increased ICP, such as severe headaches, vomiting, altered mental status, and unequal pupil size. In severe cases, ICP monitoring devices may be used to track pressure levels directly. 
3. Medication management: Depending on the severity of the subdural hematoma, patients may require medications to reduce brain swelling (e.g., mannitol or hypertonic saline), control pain (e.g., acetaminophen), or prevent seizures (e.g., phenytoin). Nurses should ensure timely administration of these medications, monitor for side effects, and educate patients and caregivers about their use. 
4. Post-surgical care: In cases where surgery is required to evacuate the hematoma, nurses play a critical role in post-operative care. This includes monitoring for signs of infection at the surgical site, managing pain, and observing for complications such as re-bleeding or seizures. Nurses must educate patients on wound care and the importance of follow-up appointments for brain imaging. 
5. Airway management and oxygenation: For patients with altered mental status, nurses should monitor respiratory status closely, ensuring the patient’s airway is clear and oxygenation is adequate. Mechanical ventilation may be necessary for patients with significant loss of consciousness or those undergoing surgery. 
6. Rehabilitation and recovery: Following treatment for subdural hematoma, many patients will require rehabilitation to regain cognitive, speech, and motor functions. Nurses should work with a multidisciplinary team to coordinate rehabilitation services and provide support for patients and their families as they adjust to potential long-term changes in health status. 

Preventing complications in subdural hematoma: The nurse’s role 

Preventing complications is a key aspect of nursing care for patients with subdural hematoma. Nurses can play an important role in: 

• Preventing falls and injuries: Since subdural hematomas often result from head injuries, nurses should implement fall prevention strategies, particularly in older adults who may be at higher risk. This includes fall-proofing the environment and using mobility aids as needed. 
• Preventing seizures: Subdural hematomas can increase the risk of seizures due to irritation of the brain tissue. Nurses should monitor for signs of seizures, including sudden jerking movements or changes in consciousness, and administer anticonvulsant medications as prescribed. 
• Monitoring for re-bleeding: After treatment for a subdural hematoma, patients remain at risk for re-bleeding, particularly if they are on anticoagulant therapy or have underlying bleeding disorders. Nurses should closely monitor for new neurological symptoms or worsening of existing ones, which could indicate a recurrent bleed. 
• Supporting cognitive and emotional health: Subdural hematomas can cause cognitive changes, including memory loss and difficulty concentrating. Nurses should provide emotional support, help patients set realistic recovery goals, and involve the family in the patient’s care plan to promote emotional well-being.