What are the management guidelines for intracranial hemorrhage in a trauma patient?

Management of Intracranial Hemorrhage in Trauma

All exsanguinating trauma patients with life-threatening hemorrhage require immediate surgical or interventional radiology control of bleeding before any other intervention, including neurological assessment. 1

Initial Prioritization Algorithm

The management sequence follows a strict hierarchy based on immediate mortality risk:

Step 1: Control Life-Threatening Hemorrhage First

• Immediate intervention (surgery and/or interventional radiology) is mandatory for all patients with exsanguinating hemorrhage, regardless of neurological status 1
• Do not delay hemorrhage control to obtain neurological imaging or assessment 1
• Persistent hypotension must be corrected before patient transfer, as it adversely affects neurological outcomes 1

Step 2: Urgent Neurological Evaluation

After hemorrhage control (or if no life-threatening hemorrhage exists):

• Perform immediate neurological evaluation: pupillary exam + Glasgow Coma Scale motor score (if feasible) 1
• Obtain urgent non-contrast brain CT scan to determine severity of brain injury 1, 2
• Complete evaluation within 15 minutes of hemorrhage stabilization 1

Step 3: Neurosurgical Intervention

• All salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention after hemorrhage control 1
• Surgical evacuation is indicated for: epidural hematoma, acute subdural hematoma with mass effect, cerebral contusion with mass effect, and obstructive hydrocephalus 1, 2

Airway Management

Immediate endotracheal intubation is mandatory for all patients with GCS ≤8 1, 2

Intubation Protocol

• Use rapid sequence induction with manual in-line cervical spine stabilization 1
• Recommended induction agents 1:
  • High-dose fentanyl (3-5 µg/kg) or alfentanil (10-20 µg/kg) or remifentanil TCI (≥3 ng/mL)
  • Ketamine 1-2 mg/kg for hemodynamically unstable patients
  • Neuromuscular blockade: suxamethonium 1.5 mg/kg or rocuronium 1 mg/kg
• Confirm tube placement with end-tidal CO₂ monitoring 1, 2

Ventilation Targets

• Maintain PaCO₂ between 4.5-5.0 kPa (approximately 34-38 mmHg) 1
• Never use prophylactic hyperventilation, as hypocapnia causes cerebral vasoconstriction and worsens brain ischemia 1, 2
• Target PaO₂ ≥13 kPa (approximately 98 mmHg) to ensure adequate cerebral oxygenation 1
• Consider PEEP 5-10 cm H₂O, which may decrease intracranial pressure and improve cerebral perfusion pressure 2

Blood Pressure Management

Maintain systolic blood pressure >100-110 mmHg or mean arterial pressure >80 mmHg at all times 1, 2

Critical Principles

• Even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological prognosis 2
• During interventions for life-threatening hemorrhage or emergency neurosurgery, maintain SBP >100 mmHg or MAP >80 mmHg 1
• In cases of difficult intraoperative bleeding control, lower values may be tolerated for the shortest possible time 1
• Never use permissive hypotension protocols designed for torso trauma in patients with traumatic brain injury, as these worsen secondary brain injury 2

Vasopressor Use

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation 2
• Have vasoconstrictor (ephedrine or metaraminol) immediately available during intubation 1
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available 2

Fluid Resuscitation

Administer 0.9% normal saline exclusively in severe head trauma 2

Fluid Management Principles

• Never use hypotonic solutions (including Ringer's lactate) in severe head trauma 2
• Avoid colloids in patients with severe head trauma 2
• Consider plasma-based resuscitation with RBCs/plasma/platelets at 1:1:1 ratio for hemorrhagic shock, then modify based on laboratory values 2, 3
• Maintain euvolemia; avoid both hypovolemia and fluid overload 1

Intracranial Pressure Monitoring

Patients at risk for intracranial hypertension require ICP monitoring regardless of the need for emergency extra-cranial surgery 1

ICP Monitoring Indications

• All comatose patients (GCS ≤8) with radiological signs of intracranial hypertension 1
• Patients with clinical evidence of transtentorial herniation 1
• Patients with significant intraventricular hemorrhage or hydrocephalus 1
• Monitor after control of life-threatening hemorrhage, even if emergency extra-cranial surgery is needed 1

ICP Management Targets

• Target ICP <20-22 mmHg 2
• Maintain cerebral perfusion pressure (CPP) 50-70 mmHg depending on autoregulation status 1
• Evidence of reduced CSF pressure should be observed within 15 minutes of starting mannitol infusion 4

Osmotic Therapy

For elevated ICP, mannitol dosing 4:

• Adults: 0.25 to 2 g/kg body weight as 15-25% solution over 30-60 minutes
• Pediatrics: 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes
• Small or debilitated patients: 500 mg/kg may be sufficient

Coagulopathy Reversal

Discontinue all antithrombotic agents immediately when intracranial hemorrhage is present or suspected 1

Warfarin Reversal

• Reverse warfarin in all patients with intracranial hemorrhage receiving therapeutic doses 1
• Administer prothrombin complex concentrate (PCC) or fresh frozen plasma plus vitamin K 1

LMWH Reversal

• Reverse LMWH in patients receiving therapeutic doses 1
• For enoxaparin given within 8 hours: protamine 1 mg per 1 mg enoxaparin (max 50 mg single dose) 1
• For enoxaparin given 8-12 hours prior: protamine 0.5 mg per 1 mg enoxaparin 1
• For dalteparin/nadroparin/tinzaparin: protamine 1 mg per 100 anti-Xa units (max 50 mg) 1

Antiplatelet Agent Management

• Do not transfuse platelets for antiplatelet-associated intracranial hemorrhage unless neurosurgical procedure is planned 1
• For patients undergoing neurosurgery: perform platelet function testing prior to transfusion if possible 1
• When platelet testing unavailable, empiric platelet transfusion may be reasonable for surgical patients 1

Coagulation Targets

• Maintain platelet count >100,000/mm³ in TBI patients 2
• Initiate massive transfusion protocol with 1:1:1 ratio if coagulopathy present 2

Hydrocephalus Management

Ventricular drainage is reasonable for hydrocephalus in patients with decreased level of consciousness 1

• Hydrocephalus occurs in 23% of all ICH patients and 55% of those with intraventricular hemorrhage 1
• Consider external ventricular drain placement for obstructive hydrocephalus 1, 2
• For short transfers with external ventricular drain in situ, seek neurosurgical advice regarding clamping to prevent overdrainage 1

Seizure Management

Administer levetiracetam for seizure prophylaxis in high-risk patients 1, 2

• Loading dose: levetiracetam 1 g (some centers use 20 mg/kg) or phenytoin 20 mg/kg (max 2 g) 1
• Administer before transfer if patient has had a seizure 1
• Implement strategies for detection and prevention of post-traumatic seizures 2

Temperature and Glucose Management

Maintain normothermia (36-37°C) as hyperthermia worsens neurological outcomes 1, 2

• Use active warming for hypothermic patients before transfer 1
• Monitor core temperature (bladder or esophageal) 1
• Optimize glucose control; hyperglycemia worsens neurological outcomes 2
• Consider insulin infusion for tighter glycemic control during acute phase 2

Imaging Requirements

Obtain non-contrast CT brain and cervical spine immediately without delay 2

• Use inframillimetric reconstructions with thickness >1mm 2
• Visualize with double window (CNS and bone) 2
• Consider CT angiography to evaluate for vascular injury or malformations 5
• Repeat imaging at 2-4 weeks to document stability before any high-risk activities 6

Transfer Considerations

Never delay transfer to specialized neurosurgical center for "stabilization" in a facility without neurosurgery 2

Pre-Transfer Requirements

• Control life-threatening hemorrhage first 1
• Secure airway if GCS ≤8 1
• Establish invasive arterial monitoring if time permits 1
• Insert intercostal drain if clinically significant pneumothorax present 1
• Obtain arterial blood gases to validate end-tidal CO₂ and check electrolytes/glucose 1

Common Pitfalls to Avoid

• Never use sedation boluses instead of continuous infusions, which causes hemodynamic instability 2
• Never place 25% mannitol in PVC bags; white precipitate may form 4
• Never administer mannitol intramuscularly or subcutaneously 4
• Do not clamp chest drains during transfer; use Heimlich valve drainage systems 1

Surgical Timing

Delaying surgery while "observing" large hematomas is inappropriate and increases mortality risk 5

• Wide craniotomy covering entire hematoma is essential 5
• Prepare for decompressive craniectomy if brain swelling occurs during evacuation 5
• Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension 2

Post-Operative Management

• Institute ICP monitoring post-operatively to detect intracranial hypertension 5, 2
• Target ICP <20-22 mmHg and CPP >60 mmHg 2
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes and communication without reducing survival 2