What is the management plan for extra axial and intra axial hemorrhage?

Management of Extra-Axial and Intra-Axial Hemorrhage

Immediate surgical evacuation or bleeding control takes absolute priority over all other interventions, as control of hemorrhage is the single most critical determinant of survival in intracranial bleeding. 1, 2

Immediate Stabilization and Resuscitation

Airway and Oxygenation:

• Secure the airway immediately in patients with decreased consciousness and provide high FiO2 to prevent secondary brain injury 2
• Establish large-bore IV access (largest bore possible including central access) for rapid fluid resuscitation 1

Hemodynamic Management:

• Target systolic blood pressure of 80-100 mmHg until bleeding is controlled in patients without brain injury 1, 2
• For patients with intracranial hemorrhage, meticulous blood pressure control is essential, though optimal targets remain under investigation 3
• Avoid vasopressors during active bleeding; reserve for after hemorrhage control 1

Activate Major Hemorrhage Protocol:

• Mobilize the major hemorrhage protocol immediately when massive bleeding is anticipated or present 1, 2
• Alert operating theater team about need for cell salvage autotransfusion 1

Laboratory Assessment and Monitoring

Baseline Studies:

• Obtain full blood count, prothrombin time (PT), activated partial thromboplastin time (aPTT), Clauss fibrinogen, and cross-match 1
• Perform near-patient testing with thromboelastography (TEG) or thromboelastometry (ROTEM) if available 1
• Single hematocrit measurements should not be used as isolated markers for bleeding 1
• Monitor serum lactate and base deficit to estimate and monitor extent of bleeding and shock 1

Coagulopathy Management

Prevention and Early Treatment:

• Administer fresh frozen plasma (FFP) at 15 ml/kg early to prevent dilutional coagulopathy if massive hemorrhage is anticipated 1, 2
• Fibrinogen <1 g/L or PT/aPTT >1.5 times normal represents established haemostatic failure and predicts microvascular bleeding 1, 2

Established Coagulopathy:

• For established coagulopathy requiring >15 ml/kg FFP, the most effective rapid fibrinogen replacement is fibrinogen concentrate or cryoprecipitate 1, 2
• Maintain platelet count above 75 × 10^9/L throughout acute management 1, 2
• In severely traumatized patients with hemorrhagic shock, implement 1:1:1 red cell:FFP:platelet transfusion regimens 1, 2

Blood Product Administration:

• Use group-specific blood when possible; reserve O-negative blood only for immediate life-threatening situations when blood is needed immediately 1, 2
• Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1, 2

Anticoagulation Reversal:

• Reverse oral anticoagulation immediately in patients with known coagulopathies 3
• There is no evidence for routine platelet transfusion in patients taking aspirin or clopidogrel 3
• Recombinant factor VIIa reduces hematoma expansion but does not improve outcome and is associated with thromboembolic complications; routine use is not recommended 3

Imaging and Surgical Decision-Making

Diagnostic Approach:

• Perform early focused sonography (FAST) for detection of free fluid in patients with suspected torso trauma 1
• Hemodynamically stable patients with suspected head, chest, or abdominal bleeding following high-energy injuries should undergo CT imaging 1
• Rapid access to imaging (ultrasound, radiography, CT) is essential; use focused assessment with sonography for trauma or early whole body CT if patient is sufficiently stable 1

Surgical Indications:

• Patients with hemorrhagic shock and identified bleeding source should undergo immediate bleeding control procedure unless initial resuscitation is successful 1
• For extra-axial hematomas causing brain herniation in children, early decompressive surgery when possible yields promising results; approximately one-third have potential for favorable outcome 4
• Low Glasgow coma scale scores at admission, longer intervals from trauma to surgery, and longer durations of brain herniation correlate with mortality 4

Damage Control Surgery:

• Employ damage control surgery in severely injured patients presenting with deep hemorrhagic shock, signs of ongoing bleeding and coagulopathy, hypothermia, acidosis, or inaccessible major anatomic injury 1
• Surgery may need to be interrupted and limited to damage control; once bleeding is controlled, abnormal physiology can be corrected 1

Post-Hemorrhage Control Management

Critical Care Admission:

• Admit all patients to critical care unit for continued monitoring after hemorrhage control 1, 2
• Monitor coagulation parameters, hemoglobin, blood gases, and wound drains to identify overt or covert bleeding 1
• Postoperative intracranial pressure (ICP) monitoring predicts outcome in patients with extra-axial hematomas 4

Physiological Normalization:

• Once bleeding is controlled, aggressively normalize blood pressure, acid-base status, and temperature 1, 2
• Active warming is required throughout management 1

Thromboprophylaxis:

• Commence standard venous thromboprophylaxis as soon as possible after bleeding is controlled, as patients rapidly develop a prothrombotic state following massive hemorrhage 1, 2
• Consider temporary inferior vena cava filtration in high-risk patients 1, 2

Critical Pitfalls to Avoid

• Do not delay surgical intervention in unstable patients while pursuing diagnostic studies—this increases mortality from ongoing hemorrhage 4
• Do not wait for laboratory results before administering blood products in obvious massive hemorrhage—clinical scenario should lead management 1
• Do not use derived fibrinogen levels—these are misleading; use Clauss fibrinogen only 1
• Do not attempt to achieve normal blood pressure during active bleeding—permissive hypotension (systolic 80-100 mmHg) is appropriate until hemorrhage control 1, 2
• High postoperative ICP values, presence of intraoperative brain swelling, and larger/thicker hematomas correlate with unfavorable outcomes 4