What are the recommended management steps for a patient with traumatic intracranial hemorrhage?

Management of Traumatic Intracranial Hemorrhage

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

Immediate Stabilization (First Contact)

Airway Management

• Perform endotracheal intubation and mechanical ventilation immediately for all severe TBI patients, beginning in the pre-hospital period 1, 2
• Confirm correct tube placement through continuous end-tidal CO2 monitoring 1, 3
• Maintain PaCO2 between 35-40 mmHg; avoid hypocapnia as it induces cerebral vasoconstriction and risks brain ischemia 4, 3
• Maintain PaO2 between 60-100 mmHg 4

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 or sedation adjustment 1, 2
• Target mean arterial pressure >80 mmHg during interventions for life-threatening hemorrhage or emergency neurosurgery 4

Neurological Assessment

• Assess severity using Glasgow Coma Scale motor component, pupillary size, and pupillary reactivity 2
• Repeat neurological examination every 15 minutes during the first 2 hours, then hourly for the following 12 hours 4
• A decrease of at least two points in Glasgow Coma Score should trigger repeat CT scan 4

Imaging Strategy

• Obtain non-contrast CT of the brain and cervical spine immediately without any delay 1, 2
• Use inframillimetric reconstructions with thickness >1mm, visualized with double window (central nervous system and bone) 1, 3
• Never delay transfer to a specialized neurosurgical center for "stabilization" at a non-neurosurgical facility 1, 2

Priority Algorithm for Polytrauma Patients

1. If life-threatening hemorrhage exists: Immediate intervention (surgery and/or interventional radiology) for bleeding control takes absolute priority 4
2. After hemorrhage control (or if no life-threatening hemorrhage): Urgent neurological evaluation with pupils, GCS motor score, and brain CT to determine severity of brain damage 4
3. If life-threatening brain lesion identified: Urgent neurosurgical consultation and intervention after hemorrhage control 4

Neurosurgical Intervention Criteria

Perform surgical evacuation for: 1, 2, 3

• 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

Intracranial Pressure Management

ICP Monitoring

• Implement ICP monitoring in severe TBI patients who cannot be neurologically assessed to detect intracranial hypertension 1, 2
• Place ICP monitor in patients at risk for intracranial hypertension (comatose patients with radiological signs of IH) regardless of need for emergency extra-cranial surgery 4
• Target cerebral perfusion pressure ≥60 mmHg once ICP monitoring is available 1

Osmotherapy for Elevated ICP

• Use mannitol 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over 30-60 minutes for reduction of intracranial pressure 5
• In pediatric patients: 1-2 g/kg body weight or 30-60 g/m² body surface area over 30-60 minutes 5
• In small or debilitated patients: 500 mg/kg may be sufficient 5
• Evidence of reduced cerebral spinal fluid pressure must be observed within 15 minutes after starting infusion 5
• In cases of cerebral herniation awaiting or during emergency neurosurgery, use osmotherapy and/or temporary hypocapnia 4

Temperature Management

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

Sedation Management

• Use propofol administered by continuous infusion (not bolus) in combination with normocapnia to decrease intracranial pressure 1, 2
• Critical pitfall: Never use bolus sedation rather than continuous infusions, which causes hemodynamic instability 1, 3
• Avoid hypotensive sedative agents 1

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 4
• Maintain prothrombin time/activated partial thromboplastin time <1.5 times normal control during interventions 4
• Initiate massive transfusion protocol with RBCs/plasma/platelets at 1:1:1 ratio, then modify based on laboratory values 1

Transfusion Thresholds

• Transfuse red blood cells for hemoglobin <7 g/dL during interventions for life-threatening hemorrhage or emergency neurosurgery 4
• Use higher threshold for RBC transfusions in patients "at risk" (elderly and/or patients with limited cardiovascular reserve due to pre-existing heart disease) 4

Ventilation Strategy

• Increase positive end-expiratory pressure (PEEP) from 0 to 5-15 cm H₂O, which is associated with decreased ICP and improved cerebral perfusion pressure 1, 2

Supportive Care Measures

• Implement detection and prevention strategies for post-traumatic seizures 1, 2
• Maintain biological homeostasis including osmolarity, glycemia, and adrenal axis function 1, 2, 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

Follow-Up Imaging

• Obtain repeat CT scan at approximately 6 hours after initial imaging 6
• If initial interval CT shows stability, progression occurs in only 1.9% of patients 6
• Patients demonstrating bleeding stability on first interval CT rarely experience expansion and can be considered for ICU discharge 6

Critical Errors to Avoid

• Never allow even brief episodes of hypotension while waiting for "adequate resuscitation" before starting vasopressors 1, 3
• Never delay transfer to specialized neurosurgical center for "stabilization" at non-neurosurgical facility 1, 2, 3
• Never use bolus sedation instead of continuous infusions 1, 3
• Avoid concomitant administration of nephrotoxic drugs or other diuretics with mannitol 5