Sedation Guidelines for Hemorrhagic Contusion
For patients with hemorrhagic contusion requiring sedation, avoid hyperventilation and excessive positive end-expiratory pressure, maintain adequate cerebral perfusion pressure with mean arterial pressure ≥65 mmHg, and use high-dose opioids (fentanyl 3-5 µg/kg or remifentanil TCI ≥3 ng/mL) combined with agents that preserve hemodynamic stability such as ketamine (1-2 mg/kg) in unstable patients. 1
Critical Ventilation Parameters
Severely hypovolemic trauma patients with hemorrhagic contusion must not be hyperventilated or subjected to excessive positive end-expiratory pressure, as this compromises cerebral perfusion and worsens outcomes. 1 This is a firm contraindication that takes precedence over standard ventilation strategies used in other trauma populations.
Blood Pressure Management During Sedation
The approach to blood pressure targets fundamentally differs based on whether traumatic brain injury is present:
For hemorrhagic contusion WITH brain injury: Maintain mean arterial pressure ≥65 mmHg to ensure adequate cerebral perfusion pressure, as the low-volume/permissive hypotension approach is contraindicated in traumatic brain injury. 1 Persistent hypotension adversely affects neurological outcomes. 1
Judicious use of vasopressors (e.g., metaraminol infusion) is recommended to offset hypotensive effects of sedative agents when other causes of hypotension have been excluded. 1
Recommended Sedation Regimen
Induction Protocol
For patients requiring intubation and sedation with hemorrhagic contusion:
High-dose opioids as first-line: Fentanyl 3-5 µg/kg, alfentanil 10-20 µg/kg, or remifentanil target-controlled infusion (Cpt ≥3 ng/mL). 1 Use lower doses in hemodynamically unstable patients with multiple trauma. 1
Induction agent selection prioritizing hemodynamic stability: Ketamine 1-2 mg/kg is particularly useful in hemodynamically unstable patients and does not compromise cerebral perfusion. 1 Target-controlled infusion regimes facilitate subsequent transport sedation. 1
Neuromuscular blockade: Suxamethonium 1.5 mg/kg or rocuronium 1 mg/kg. 1
Have vasoconstrictors immediately available (ephedrine or metaraminol) to treat any immediate hypotension during induction. 1
Maintenance Sedation
Emergency physicians and intensivists should select from commonly used agents including opioids, benzodiazepines, ketamine, propofol, remifentanil, dexmedetomidine, etomidate, based on hemodynamic stability and need for neurological assessment. 1 However, in the context of hemorrhagic contusion with potential for increased intracranial pressure, agents preserving cerebral perfusion pressure are preferred.
Monitoring Requirements
Transduced direct arterial pressure monitoring (with transducer at tragus level) facilitates stable hemodynamic management; if time does not allow pre-intubation, non-invasive blood pressure at 1-minute intervals is required peri-induction. 1
Arterial blood gases to validate oxygenation and end-tidal CO₂, checking A-a gradient and electrolytes. 1
Core temperature monitoring (bladder or esophageal) targeting normothermia (36-37°C). 1
Critical Pitfalls to Avoid
Never use permissive hypotension strategies (systolic BP 80-100 mmHg) that are appropriate for hemorrhagic shock without brain injury—this is contraindicated in traumatic brain injury including hemorrhagic contusion. 1
Avoid hyperventilation, which was historically used for intracranial pressure management but worsens cerebral ischemia. 1
Do not use excessive PEEP, as this impairs venous drainage and increases intracranial pressure. 1
Hypertension during sedation may indicate worsening neurological status or inadequate sedation—address the underlying cause rather than simply increasing sedative doses. 1
Additional Considerations
If seizures occur, load with anticonvulsants (levetiracetam 1 g or 20 mg/kg, or phenytoin 20 mg/kg, max 2 g) before or during sedation. 1
Secure the endotracheal tube with tape rather than ties to avoid occlusion of venous drainage. 1
Blood glucose should be maintained at 6-10 mmol/L during sedation. 1