Initial Imaging and Diagnostic Workup for Suspected Traumatic Brain Bleed
Order an urgent non-contrast head CT scan immediately for any patient with suspected traumatic brain injury—this is the definitive diagnostic test and should not be delayed. 1
Immediate Diagnostic Orders
Primary Imaging
- Non-contrast head CT scan is the mandatory first-line imaging study for all patients with suspected traumatic brain hemorrhage 2, 1
- Haemodynamically stable patients with suspected head bleeding following high-energy injuries should undergo CT assessment 2
- Do not rely on clinical characteristics alone to determine whether symptoms are due to ischemia or hemorrhage—neuroimaging is mandatory 1
Essential Laboratory Studies
- Coagulation panel including PT/INR and aPTT to assess for coagulopathy 2, 3
- Complete blood count with hemoglobin and platelet count 4
- Serum lactate to estimate and monitor the extent of bleeding and shock 2
- Base deficit to estimate and monitor the extent of bleeding and shock 2
- Type and crossmatch blood products in preparation for potential transfusion 2
Critical caveat: Single hematocrit measurements should not be employed as an isolated laboratory marker for bleeding 2
Clinical Assessment Priorities
Neurological Evaluation
- Perform urgent neurological evaluation including pupillary assessment and Glasgow Coma Scale (GCS) motor score 2, 1
- Document the mechanism of injury, as this represents an important screening tool to identify patients at risk for significant traumatic hemorrhage 2
- Assess for loss of consciousness, which is a significant predictor of positive CT findings (Wald=7.468, p=0.008) 5
Hemodynamic Monitoring
- Maintain mean arterial pressure ≥80 mmHg in patients with combined hemorrhagic shock and severe traumatic brain injury 2
- Maintain systolic blood pressure >100 mmHg during initial interventions 1, 4
- For isolated TBI without hemorrhagic shock, different blood pressure targets may apply, but cerebral perfusion must be prioritized 2
Special Considerations for High-Risk Patients
Anticoagulated or Antiplatelet Therapy Patients
- Patients taking warfarin, clopidogrel, or aspirin have a 29% incidence of intracranial hemorrhage even with GCS of 15 5
- Antiplatelet therapy (APT) patients may have equal or higher risk of traumatic intracranial hemorrhage compared to anticoagulation therapy patients (RR 1.72, p=0.01) 6
- These patients require head CT regardless of seemingly minor mechanism, especially if loss of consciousness occurred 5
- Obtain detailed medication history including all anticoagulants and antiplatelet agents 1
Timing of Repeat Imaging
- 96% of intracranial hemorrhages stop progressing by 24 hours and 99% by 48 hours post-injury 7
- Early repeat CT (within 6-12 hours) may identify hemorrhages that have stopped progressing 7
- Over three-quarters of intracranial hemorrhages have stopped by the time of initial CT (<2 hours from arrival) 7
Adjunctive Diagnostic Modalities
For Polytrauma Patients
- FAST (Focused Assessment with Sonography for Trauma) should be employed for detection of free fluid in patients with suspected torso trauma 2
- Patients with significant free intraabdominal fluid and hemodynamic instability should undergo urgent surgery 2
Critical Management Pitfalls to Avoid
- Do not delay CT imaging to obtain laboratory results if the patient is stable enough for transport to the scanner 1
- Avoid hyperventilation unless there are signs of imminent cerebral herniation, as routine hyperventilation worsens outcomes in TBI patients 2
- Do not use hypotonic solutions such as Ringer's lactate in patients with severe head trauma 2
- Avoid hypotension and hypoxia, which worsen secondary brain injury 1