Supportive Measure for Traumatic Subarachnoid Hemorrhage
The provider is most likely to order norepinephrine (Levophed) to maintain cerebral perfusion pressure above 50 mmHg (Option D), as maintaining adequate blood pressure and cerebral perfusion is a fundamental priority in traumatic brain injury management, including traumatic subarachnoid hemorrhage.
Blood Pressure and Cerebral Perfusion Management
Maintaining systolic blood pressure >110 mmHg and mean arterial pressure (MAP) >90 mmHg is essential in traumatic subarachnoid hemorrhage to ensure adequate cerebral perfusion pressure 1.
Norepinephrine and other vasopressors (ephedrine, metaraminol) are standard medications that should accompany transfer and management of brain-injured patients 1.
The target CPP threshold of 50 mmHg mentioned in the question is actually below optimal targets; cerebral perfusion should be maintained with MAP >90 mmHg, which typically corresponds to CPP >60-70 mmHg 1.
Why Not the Other Options
Targeted Temperature Management to 34°C (Option A)
Hypothermia at 33-35°C may be applied in traumatic brain injury, but only after bleeding from other sources has been controlled 1.
In the acute setting of a motor vehicle crash with suspected traumatic SAH, the priority is maintaining normothermia and preventing hypothermia, not inducing therapeutic hypothermia 1.
For aneurysmal SAH, targeted temperature management is only suggested for refractory intracranial hypertension, not as routine supportive care 1.
Levetiracetam/Keppra (Option B)
While levetiracetam is listed as an appropriate medication to have available for brain-injured patients (particularly for seizure management) 1, prophylactic antiepileptic therapy is not routinely recommended in traumatic brain injury.
Anticonvulsants should be used to treat actual seizures, not as routine prophylaxis in all traumatic SAH cases 1.
Nimodipine/Nimotop (Option C)
This is the critical distinction: nimodipine is specifically indicated for aneurysmal (spontaneous) subarachnoid hemorrhage, NOT traumatic subarachnoid hemorrhage 1, 2.
The 2023 American Heart Association guidelines clearly state that oral nimodipine (60 mg every 4 hours for 21 days) should be administered to all patients with aneurysmal SAH to prevent delayed cerebral ischemia and improve functional outcomes 1.
A systematic review specifically examining nimodipine in traumatic subarachnoid hemorrhage found no benefit: poor outcome occurred in 39% of nimodipine-treated patients versus 40% of placebo patients (OR 0.88,95% CI 0.51-1.54), and mortality was identical at 26-27% 3.
The evidence supporting nimodipine comes exclusively from aneurysmal SAH trials 4, and these results do not translate to traumatic SAH 3.
Clinical Context and Reasoning
In a motor vehicle crash victim with traumatic subarachnoid hemorrhage:
The immediate priorities are maintaining adequate cerebral perfusion, oxygenation (PaO₂ ≥13 kPa), and normocapnia (PaCO₂ 4.5-5.0 kPa) 1.
Blood pressure support with vasopressors is fundamental to prevent secondary brain injury from hypotension 1.
The pathophysiology of traumatic SAH differs from aneurysmal SAH—there is no aneurysm to secure, and the mechanism of delayed cerebral ischemia is different 3.
Common Pitfalls
Do not confuse traumatic SAH with aneurysmal SAH: nimodipine has proven benefit only in the latter 1, 3.
Do not allow blood pressure to drop below critical thresholds (systolic <110 mmHg, MAP <90 mmHg) in traumatic brain injury patients, as this worsens outcomes 1.
Avoid prophylactic hypothermia in the acute trauma setting when bleeding may not be controlled 1.