From the Guidelines
The first line treatment for traumatic brain injury (TBI) with brain bleed is immediate administration of tranexamic acid (TXA) at a loading dose of 1 g infused over 10 min, followed by an i.v. infusion of 1 g over 8 h, as soon as possible, if feasible en route to the hospital, and within 3 h after injury. This recommendation is based on the European guideline on management of major bleeding and coagulopathy following trauma: sixth edition 1.
Key Interventions
- Airway management with rapid sequence intubation if the Glasgow Coma Scale is less than 8
- Maintaining systolic blood pressure above 90 mmHg
- Ensuring adequate oxygenation with target PaO2 > 60 mmHg
- Keeping the head elevated at 30 degrees
- Hyperosmolar therapy with mannitol (0.25-1 g/kg IV) or hypertonic saline (3% solution at 0.5-1 mL/kg/hr) to reduce ICP
- Seizure prophylaxis with levetiracetam (500-1000 mg IV twice daily) or phenytoin (loading dose 15-20 mg/kg IV, then 100 mg IV every 8 hours) for 7 days post-injury
Surgical Intervention
Surgical intervention, including craniotomy or decompressive craniectomy, is often necessary for significant hematomas causing mass effect or midline shift. The goal of these interventions is to minimize secondary brain injury by preventing hypoxia, hypotension, and elevated intracranial pressure, which can worsen the primary injury and lead to poorer outcomes.
Additional Considerations
- Maintenance of a platelet count above 50×10^9/l in patients with ongoing bleeding and/or traumatic brain injury 1
- Use of point-of-care tests, such as TEG or ROTEM, to evaluate coagulation function and guide transfusion decisions 1
- Consideration of a transfusion protocol of RBCs/plasma/PLTs at a ratio of 1:1:1, which may be modified according to laboratory values 1
From the Research
First Line Treatment for Traumatic Brain Injury with Brain Bleed
The first line treatment for traumatic brain injury with brain bleed is a topic of ongoing research and debate.
- Tranexamic acid (TXA) has been studied as a potential treatment for traumatic brain injury with brain bleed, with some studies suggesting it may reduce hemorrhage growth and improve outcomes 2, 3.
- The CRASH-2 trial found that TXA was likely to be associated with a reduction in hemorrhage growth, fewer focal ischemic lesions, and fewer deaths in patients with traumatic brain injury 2.
- The CRASH-3 trial is an ongoing international, multicenter, pragmatic, randomized, double-blind, placebo-controlled trial to quantify the effects of the early administration of TXA on death and disability in patients with traumatic brain injury 4.
- A systematic review and network meta-analysis of randomized controlled trials found that a 2-g bolus of TXA may be the optimal dose for treating traumatic brain injury, with lower mortality rates compared to a 1-g bolus followed by 1-g maintenance TXA or placebo 5.
- However, another study found that TXA did not seem to improve functional outcomes and cannot be routinely recommended, highlighting the need for further research to determine which head injury subpopulations are most likely to benefit from TXA and which patients are at increased risk for harm 6.
Key Findings
- TXA may reduce hemorrhage growth and improve outcomes in patients with traumatic brain injury 2, 3.
- The optimal dose of TXA for treating traumatic brain injury is unclear, with some studies suggesting a 2-g bolus may be the most effective dose 5.
- Further research is needed to determine the effectiveness and safety of TXA in patients with traumatic brain injury, particularly in different subpopulations and with different dosing regimens 4, 6.