What is the best management approach for a patient with a head injury and intracranial bleed?

Managing Head Injury with Intracranial Bleed

Immediately secure the airway through endotracheal intubation and mechanical ventilation, maintain systolic blood pressure >110 mmHg using vasopressors without delay, and obtain urgent non-contrast CT of the brain to guide neurosurgical intervention. 1, 2

Initial Resuscitation and Hemorrhage Control

If the patient has life-threatening hemorrhage from other injuries, control bleeding first before neurological evaluation. 3

• All exsanguinating patients require immediate intervention (surgery and/or interventional radiology) for bleeding control before addressing the head injury 3
• Once hemorrhage is controlled or if no life-threatening bleeding exists, proceed immediately to neurological assessment 3

Airway Management

Perform endotracheal intubation and mechanical ventilation immediately for all severe TBI patients. 1, 2

• Confirm correct tube placement through end-tidal CO2 monitoring 1, 2
• Maintain PaCO2 between 35-40 mmHg during all interventions 3
• Maintain PaO2 between 60-100 mmHg 3
• Avoid hyperventilation except temporarily in cases of cerebral herniation awaiting emergency neurosurgery 3

Hemodynamic Management

Maintain systolic blood pressure >110 mmHg from the moment of first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome. 1, 2

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation 1, 2
• During interventions for life-threatening hemorrhage or emergency neurosurgery, maintain SBP >100 mmHg or MAP >80 mmHg 3
• Lower blood pressure values may be tolerated only for the shortest possible time during difficult intraoperative bleeding control 3

Neurological Assessment

Assess severity using Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity—these are the most robust predictors of 6-month neurological outcome. 1

• Perform urgent neurological evaluation (pupils + GCS motor score if feasible) to determine severity of brain damage 3

Imaging

Obtain non-contrast CT of the brain and cervical spine immediately without any delay. 1, 2

• Do not delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 1, 2
• CT scan guides neurosurgical procedures and monitoring techniques 1, 2

Neurosurgical Intervention Criteria

After control of life-threatening hemorrhage, all salvageable patients with life-threatening brain lesions require urgent neurosurgical consultation and intervention. 3

Perform surgical evacuation for: 1

• Symptomatic extradural hematoma
• Acute subdural hematoma with thickness >5mm and midline shift >5mm
• Brain contusions with mass effect
• Acute hydrocephalus requiring drainage
• Open displaced skull fracture
• Closed displaced skull fracture with brain compression

Coagulation Management

Maintain platelet count >100,000/mm³, as coagulopathy is associated with intracranial bleeding progression and unfavorable neurological outcomes. 1, 2

• For patients requiring emergency neurosurgery (including ICP probe insertion), maintain platelet count >50,000/mm³ at minimum, though higher values are advisable 3
• Maintain prothrombin time (PT)/activated partial thromboplastin time (aPTT) <1.5 normal control during interventions 3
• If massive transfusion is needed, initiate RBCs/plasma/platelets at 1:1:1 ratio, then modify based on laboratory values 2

Transfusion Thresholds

Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery. 3

• Higher thresholds may be used in elderly patients or those with limited cardiovascular reserve due to pre-existing heart disease 3

Intracranial Pressure Monitoring

Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension and guide pressure-directed therapy. 1, 2

• Patients in coma with radiological signs of intracranial hypertension require ICP monitoring regardless of need for emergency extra-cranial surgery 3
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available 2

Management of Intracranial Hypertension

In cases of cerebral herniation awaiting or during emergency neurosurgery, use osmotherapy and/or hypocapnia temporarily. 3

• Mannitol can be administered at 0.25 to 2 g/kg body weight as a 15% to 25% solution over 30-60 minutes for reduction of intracranial pressure 4
• In pediatric patients, use 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes 4
• Use propofol by continuous infusion (not bolus) in combination with normocapnia to decrease intracranial pressure 1
• Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension 2

Temperature Management

Maintain normothermia using targeted temperature control, as hyperthermia increases complications and unfavorable outcomes including death. 1, 2

• Early application of measures to reduce heat loss and warm hypothermic patients should be employed 3
• Hypothermia at 33-35°C for 48 hours may be applied once bleeding from other sources has been controlled 3

Ventilation Strategy

Increasing PEEP from 0 to 5-15 cm H₂O is associated with decreased ICP and improved cerebral perfusion pressure. 1

Seizure Management

Implement detection and prevention strategies for post-traumatic seizures. 1, 2

Critical Pitfalls to Avoid

• Never use sedation in bolus instead of continuous infusions, which causes hemodynamic instability 2
• Never delay transfer to a specialized neurosurgical center for "stabilization" in a facility without neurosurgery 1, 2
• Avoid hypotensive sedative agents 2
• Do not add mannitol to whole blood for transfusion 4

Supportive Care

Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function. 1, 2

• Implement mechanical thromboprophylaxis with intermittent pneumatic compression and/or anti-embolic stockings as soon as possible 3
• Pharmacological thromboprophylaxis should be employed within 24 hours after bleeding has been controlled 3
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients, which improves outcomes, reduces length of stay, and enhances communication with family members without reducing survival 1, 2