What is the further management for a patient with hemorrhage or hematoma, or with bacterial infection?

Management of Hemorrhage, Hematoma, or Bacterial Infection

For intracranial hemorrhage or hematoma with neurological deterioration, immediate surgical evacuation is the priority to reduce mortality, while bacterial infections require source control and appropriate antibiotic therapy with attention to altered pharmacokinetics in hemorrhagic patients.

Intracranial Hemorrhage/Hematoma Management

Immediate Assessment and Stabilization

• Secure the airway immediately in patients with Glasgow Coma Scale (GCS) ≤8 or signs of neurological deterioration to prevent hypoxia and secondary brain injury 1
• Maintain oxygen saturation >94% and systolic blood pressure >100 mmHg to ensure adequate cerebral perfusion 1, 2
• Obtain non-contrast CT scan immediately as the gold standard for identifying acute hemorrhage 3, 1, 2
• Consider CT angiography to identify active bleeding (contrast extravasation), which indicates high risk of hematoma expansion 3, 1

Surgical Indications by Location

Cerebellar Hemorrhage (Class I Recommendation):

• Immediate surgical removal with or without external ventricular drain (EVD) is recommended for patients with cerebellar ICH who are deteriorating neurologically, have brainstem compression and/or hydrocephalus from ventricular obstruction, or have cerebellar ICH volume ≥15 mL 3, 2
• EVD alone may be harmful when basal cisterns are compressed, as it may be insufficient when intracranial hypertension impedes brainstem blood supply 3

Supratentorial Hemorrhage:

• Craniotomy for hematoma evacuation may be considered as a life-saving measure in patients who are deteriorating, despite unclear benefit for overall functional outcomes 3
• Decompressive craniectomy with or without hematoma evacuation may be considered for patients in coma, with large hematomas causing significant midline shift, or with elevated ICP refractory to medical management to reduce mortality 3, 2

Epidural Hematoma:

• Immediate surgical evacuation is indicated for patients with neurological deterioration, brainstem compression, or signs of cerebral herniation 1
• Wide craniotomy covering the hematoma is recommended to evacuate the hematoma, control bleeding, and prevent reaccumulation 4

Medical Management to Control ICP

• Prevent hyperthermia as it increases cerebral oxygen demand and worsens secondary brain injury 1
• Treat seizures aggressively as they increase metabolic demand 1
• Consider ICP monitoring in patients with GCS ≤8, hydrocephalus, or clinical evidence of transtentorial herniation 1, 2
• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg 1

Reversal of Coagulopathy

• Reverse warfarin immediately with prothrombin complex concentrate (PCC) or fresh frozen plasma 1, 2
• Use specific reversal agents for novel oral anticoagulants (NOACs) when available 1
• Monitor prothrombin time during treatment and administer vitamin K (10 mg weekly) if PT is prolonged 5

Timing Considerations

• The commonly accepted goal is surgery within 4 hours of injury for epidural hematoma 1
• For cerebellar hemorrhage, immediate surgical evacuation is recommended when indicated 3
• Do not delay transfer to a neurosurgical center; lack of critical care beds should never be a reason to reject admission of patients requiring emergency surgery 1

Massive Hemorrhage (Non-Intracranial) Management

Immediate Actions

• Control obvious bleeding points with pressure, tourniquet, or hemostatic dressings 3
• Establish large-bore IV access—ideally 8-Fr central venous catheter in adults 3
• Obtain baseline labs: full blood count, PT, aPTT, Clauss fibrinogen, and cross-match 3
• Undertake near-patient testing (TEG or ROTEM) if available 3

Resuscitation Strategy

• Resuscitate with warmed blood and blood components, not crystalloids 3
• Blood availability hierarchy: Group O (fastest) → group-specific → cross-matched 3
• Actively warm the patient and all transfused fluids 3
• Restore organ perfusion but do not aggressively normalize blood pressure until bleeding is controlled 3

Coagulation Management

• Prevent dilutional coagulopathy by early infusion of fresh frozen plasma (FFP) 3
• Target fibrinogen level >1.5 g/L; for fibrinogen <1 g/L, administer fibrinogen concentrate 3-4g or cryoprecipitate 3
• Anticipate and treat consumptive coagulopathy aggressively, particularly in obstetric hemorrhage, trauma with head injury, and sepsis 3

Definitive Control

• Surgery must be considered early and may need to be limited to "damage control" procedures 3
• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature, but avoid vasopressors 3
• Rapid access to imaging (ultrasound, CT) or surgery is essential 3

Post-Resuscitation Care

• Admit to critical care area for monitoring of coagulation, hemoglobin, blood gases, and wound drains 3
• Commence venous thromboprophylaxis as soon as bleeding is controlled, as patients rapidly develop a prothrombotic state 3
• Combined pharmacological and intermittent pneumatic compression should be employed within 24 hours after bleeding control 3

Bacterial Infection Management in Hemorrhagic Patients

Antibiotic Considerations

• Risk of infection increases in patients resuscitated with large volumes of blood products 6
• Current guidelines recommend re-dosing prophylactic antibiotics for every 10 units of blood products administered 6
• Hemorrhage and transfusion decrease serum and tissue antibiotic concentrations, though clinical relevance remains debated 6

Specific Infection Scenarios

Intracranial Abscess with Hemorrhage:

• No delay in cardiac or neurosurgical intervention is recommended for patients with cerebral abscess 3

Vascular Graft Infections:

• Two-stage procedure is preferred: extra-anatomic bypass followed by excision of infected graft with débridement 3
• For MRSA, Pseudomonas, or multidrug-resistant organisms, operative mortality ranges 0-18%, with higher complication rates 3

Monitoring and Prevention

• Monitor for medical complications including pneumonia, cardiac events, and acute kidney injury 2
• Implement fever management and seizure prophylaxis protocols 2
• If Clostridium difficile-associated diarrhea is suspected, discontinue antibiotics not directed against C. difficile and institute appropriate fluid/electrolyte management 5

Critical Pitfalls to Avoid

• Do not use calcium-containing diluents with ceftriaxone as precipitation can occur 5
• Avoid hyperventilation during mechanical ventilation as it increases mortality and decreases cardiac output 1
• Do not use EVD alone for cerebellar ICH with compressed basal cisterns 3
• Never delay neurosurgical consultation or transfer for patients requiring emergency surgery 1