What is the management plan for brain bleeding from head trauma?

Management of Brain Bleeding from Head Trauma

Immediate non-contrast head CT is mandatory for all patients with suspected traumatic brain injury, followed by urgent neurosurgical consultation if intracranial hemorrhage is confirmed, while simultaneously maintaining mean arterial pressure ≥80 mmHg and correcting any coagulopathy. 1

Immediate Diagnostic Workup

Imaging Priority

• Obtain urgent non-contrast head CT scan immediately without delaying for laboratory results if the patient is stable enough for transport 1
• Non-contrast head CT is the definitive first-line imaging study and should not be delayed 1
• For hemodynamically stable patients with high-energy injuries, proceed directly to CT assessment 1

Essential Laboratory Studies

• Order coagulation panel (PT/INR, aPTT) to evaluate for coagulopathy 1
• Obtain complete blood count with hemoglobin and platelet count 1
• Measure serum lactate to estimate extent of bleeding and shock 1
• Measure base deficit as an alternative marker for bleeding and tissue hypoperfusion 1
• Type and crossmatch blood products in preparation for potential transfusion 1

Neurological Assessment

• Perform urgent neurological evaluation including pupillary assessment and Glasgow Coma Scale (GCS) motor score 1
• Document mechanism of injury as this identifies patients at risk for significant hemorrhage 1

Hemodynamic Management

Blood Pressure Targets

• Maintain mean arterial pressure ≥80 mmHg in patients with severe traumatic brain injury (GCS <8) 2, 3
• Maintain systolic blood pressure >100 mmHg during initial interventions 1, 3
• For patients with combined hemorrhagic shock and severe TBI, prioritize cerebral perfusion with MAP ≥80 mmHg 1

Fluid Resuscitation Strategy

• Use 0.9% normal saline as the crystalloid of choice for fluid resuscitation in brain injury 3
• Avoid hypotonic solutions such as Ringer's lactate in patients with severe head trauma as they can worsen cerebral edema 2
• Restrict colloid use due to adverse effects on hemostasis 2
• For isolated TBI without hemorrhagic shock, avoid restricted volume strategies that may compromise cerebral perfusion 2

Vasopressor Support

• Administer noradrenaline in addition to fluids if target arterial pressure cannot be maintained 2
• Infuse dobutamine if myocardial dysfunction is present 2

Coagulation Management

Platelet Transfusion

• Maintain platelet count above 50×10⁹/L in patients with ongoing bleeding and/or traumatic brain injury 3
• This threshold is critical for patients with TBI regardless of active bleeding status 3

Red Blood Cell Transfusion

• Transfuse red blood cells when hemoglobin level is <7 g/dL 3
• Consider higher transfusion threshold for elderly patients or those with limited cardiovascular reserve 3
• Target hemoglobin of 70-90 g/L if erythrocyte transfusion is necessary 2

Coagulopathy Reversal

• Perform early, repeated hemostasis monitoring including PT/INR, fibrinogen, and platelet counts 2
• Verify absence of coagulopathy before considering any elective interventions 4

Neurosurgical Considerations

Immediate Consultation

• Obtain urgent neurosurgical consultation immediately after CT confirms intracranial hemorrhage 1
• Do not delay consultation for additional workup 1
• All salvageable patients with life-threatening brain lesions require immediate neurosurgical evaluation 1

Intracranial Pressure Management

• Mannitol 0.25 to 2 g/kg body weight as 15-25% solution over 30-60 minutes for reduction of intracranial pressure 5
• For pediatric patients: 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes 5
• Use filter in administration set when infusing 25% mannitol 5
• Monitor renal function closely as mannitol can cause acute kidney injury 5

Critical Pitfalls to Avoid

Respiratory Management

• Avoid routine hyperventilation as it worsens outcomes in TBI patients 1
• Only use hyperventilation if there are signs of imminent cerebral herniation 1

Secondary Brain Injury Prevention

• Avoid hypotension and hypoxia, which worsen secondary brain injury 1
• Do not use hypotonic fluids in severe head trauma 2

Monitoring Complications

• Mannitol may increase cerebral blood flow and risk of postoperative bleeding in neurosurgical patients 5
• Mannitol may worsen intracranial hypertension in children with generalized cerebral hyperemia during first 24-48 hours post-injury 5
• Monitor electrolytes (sodium, potassium) carefully during mannitol administration 5

Thromboprophylaxis Timing

• Apply early mechanical thromboprophylaxis with intermittent pneumatic compression while patient is immobile and has bleeding risk 2
• Delay pharmacological thromboprophylaxis until at least 24 hours after bleeding has been controlled 2, 4
• Combine pharmacological and mechanical prophylaxis within 24 hours after bleeding control until patient is mobile 2
• Do not use graduated compression stockings 2

Special Populations

Anticoagulated Patients

• Patients on anticoagulants have increased risk of initial hemorrhage and mortality 6
• Larger bleeds are associated with substantially higher mortality risk 7
• The risk of delayed intracranial hemorrhage in anticoagulated patients with normal initial CT is approximately 0.6% 8

Antiplatelet Therapy

• Avoid routine use of point-of-care platelet function monitoring devices in trauma patients on antiplatelet therapy 2
• Patients on antiplatelet drugs may have higher risk of intracranial bleeding compared to general population 9