What is the immediate management of a patient with suspected traumatic intracranial hemorrhage, including urgent non‑contrast head CT, airway and oxygenation, blood pressure control, reversal of anticoagulants or antiplatelet agents, and criteria for surgical evacuation?

Immediate Management of Traumatic Intracranial Hemorrhage

For suspected traumatic intracranial hemorrhage, immediately secure the airway if GCS ≤8, obtain urgent non-contrast head CT within 30 minutes, maintain systolic blood pressure >110 mmHg, rapidly reverse anticoagulation with appropriate agents, and obtain emergent neurosurgical consultation for any life-threatening lesions or cerebellar hemorrhages with neurological deterioration.

Airway and Oxygenation

Secure the airway via tracheal intubation for any patient with GCS ≤8 1. This is a clear indication for airway protection and should not be delayed 2.

• Use rapid sequence induction with high-dose fentanyl or alfentanil, an induction agent that maintains adequate mean arterial pressure, and a neuromuscular blocking agent 1
• Maintain manual in-line cervical spine stabilization during intubation 1
• Apply cricoid pressure to prevent aspiration 1
• Monitor end-tidal CO₂ (EtCO₂) continuously to confirm proper tube placement and maintain PaCO₂ between 35-40 mmHg (4.5-5.0 kPa) 3, 4
• Maintain PaO₂ ≥60 mmHg (≥13 kPa) to prevent hypoxia-induced secondary brain injury 1, 2

Critical pitfall: Hypocapnia induces cerebral vasoconstriction and increases risk of brain ischemia, while hypercapnia worsens intracranial pressure 3.

Blood Pressure Management

Maintain systolic blood pressure >110 mmHg or mean arterial pressure >80 mmHg 3, 1, 4. A single episode of hypotension (SBP <90 mmHg) markedly worsens neurological outcome and mortality 3.

• Correct hypotension immediately with vasopressors (phenylephrine or norepinephrine) rather than waiting for fluid resuscitation or sedation adjustment 3
• Avoid hypotensive induction agents for sedation 3
• For patients with systolic BP 150-220 mmHg and confirmed ICH, acutely lower SBP to 140 mmHg as this improves functional outcomes 4
• Use nicardipine over labetalol for BP control as it achieves goal BP faster with fewer treatment failures 4
• Never allow SBP to drop below 110 mmHg 4

Urgent Diagnostic Imaging

Obtain non-contrast head CT immediately—within 30 minutes of arrival 4. Do not delay imaging for any reason 4.

• CT without contrast using sections ≤1mm is the reference standard 3
• Visualize with double fenestration (brain and bone windows) 3
• Liberal and urgent CT imaging is recommended even in patients on anticoagulants/antiplatelets who appear clinically well, as clinical findings alone cannot reliably identify ICH 5
• In hemodynamically unstable polytrauma patients, stabilize hemorrhage and hemodynamics before whole-body CT 3

Additional Vascular Imaging Indications

Perform CT angiography of supra-aortic and intracranial vessels if any of these risk factors are present 3:

• Cervical spine fracture
• Focal neurological deficit unexplained by brain imaging
• Horner syndrome
• LeFort II or III facial fractures
• Basilar skull fractures
• Soft tissue neck injuries

Reversal of Anticoagulation/Antiplatelet Agents

Immediately discontinue and reverse anticoagulation in all patients with traumatic ICH 4. Rapid reversal (within 1.9 hours vs 4.3 hours) significantly reduces ICH progression and mortality from 48% to 10% 6.

Specific Reversal Agents:

• Warfarin: Administer 4-factor prothrombin complex concentrate (4F-PCC) immediately 4. Fresh frozen plasma can be used but PCC is preferred 6
• Heparin: Give protamine sulfate 4
• Dabigatran: Administer idarucizumab 4
• Factor Xa inhibitors (rivaroxaban, apixaban): Give andexanet alfa or 4F-PCC 4

Critical consideration: Neither initial GCS nor INR reliably identifies which anticoagulated patients have ICH—imaging is mandatory 6. Patients on clopidogrel, aspirin, or combination antiplatelet therapy have 2.5-fold increased risk of ICH 5.

Neurosurgical Consultation and Intervention

Obtain urgent neurosurgical consultation for all patients with life-threatening brain lesions 2.

Absolute Indications for Emergency Surgery:

• Cerebellar hemorrhage with neurological deterioration, brainstem compression, or hydrocephalus from ventricular obstruction requires immediate surgical evacuation 3, 2
• Initial ventricular drainage instead of surgical evacuation is NOT recommended for cerebellar hemorrhage 3

Relative Indications for Surgery:

• Supratentorial hematoma evacuation may be considered as life-saving measure in deteriorating patients 3
• Decompressive craniectomy with or without hematoma evacuation may reduce mortality in comatose patients with large hematomas, significant midline shift, or elevated ICP refractory to medical management 3
• External ventricular drainage for persistent intracranial hypertension despite sedation and correction of secondary insults 3

Important nuance: For most supratentorial ICH, the benefit of surgery is not well established, and early evacuation is not clearly superior to evacuation only when patients deteriorate 3. The decision requires individualized risk-benefit discussion between the multidisciplinary team and patient surrogate 3.

Intracranial Pressure Management

Position patient with head-of-bed elevated 20-30 degrees to facilitate venous drainage and reduce ICP 1, 4.

Additional ICP management strategies 4:

• Treat exacerbating factors: hypoxia, hypercarbia, hyperthermia
• Consider osmotherapy with mannitol for deteriorating patients
• Hyperventilation can be used as temporizing measure for herniation syndromes only

Avoid albumin solutions: 4% albumin increases mortality in severe TBI patients (24.5% vs 15.1% with normal saline) 3.

Fluid Management

• Use isotonic saline (0.9% NaCl) for resuscitation 4
• Avoid hypotonic or hypo-osmolar fluids which worsen cerebral edema 1, 4
• Mild fluid restriction may help manage brain edema 4

Seizure Prophylaxis

Routine antiepileptic prophylaxis is NOT recommended for primary prevention of post-traumatic seizures 3. Treat only if seizures occur, using short-acting medications for seizures within 24 hours 4.

Monitoring and Disposition

• Admit to ICU or dedicated stroke unit with neuroscience expertise 4
• Maintain nurse-to-patient ratio of 1:2 for first 24 hours 4
• Perform neurological assessments hourly for first 24 hours using validated scales 4
• Continuous cardiac monitoring for 24-72 hours 4

Repeat CT imaging: Routine repeat head CT at 6 hours in stable patients with mild TBI (GCS ≥13) has limited utility, as clinically significant delayed hemorrhage requiring intervention occurs in only 0.3% of cases 7. Repeat imaging should be guided by clinical deterioration rather than routine protocol 7.