Traumatic intracerebral hemorrhage

Background

• Classification based on GCS
  • 14-15: Mild
  • 9-13: Moderate
  • 3-8: Severe

Diagnosis

• Monitor for increased ICP
  • HA, N/V, sz, lethargy, HTN, bradycardia, agonal respirations, posturing
• Monitor for herniation
  • Ipsilateral fixed and dilated pupil
  • Contralateral motor paralysis
• B/l pinpoint pupils suggests opiate use or pontine lesion

Workup

Workup

• Consider head CT (rule out intracranial hemorrhage)
  • Use validated decision rule to determine need
  • Avoid CT in patients with minor head injury who are at low risk based on validated decision rules.
• Consider cervical and/or facial CT

Differential Diagnosis

Intracranial Hemorrhage Types

• Intra-axial
  • Hemorrhagic stroke (Spontaneous intracerebral hemorrhage)
  • Traumatic intracerebral hemorrhage
• Extra-axial
  • Epidural hemorrhage
  • Subdural hemorrhage
  • Subarachnoid hemorrhage (aneurysmal intracranial hemorrhage)

Maxillofacial Trauma

• Ears
  • Auricular hematoma
• Nose
  • Nasal fracture
  • Nasal septal hematoma
• Oral
  • Dental trauma
  • Lip laceration
  • Tongue laceration
• Other face
  • Le Fort fractures
  • Mandible fracture
• Zygomatic arch fracture
• Zygomaticomaxillary (tripod) fracture
• Related
  • Head trauma (main)
    • Skull fracture
    • Skull fracture (peds)
    • Basilar skull fracture
  • Orbital trauma
    • Eyelid laceration
  • Scalp laceration

Management

• Pretreatment w/ lidocaine has not been shown to improve outcomes
• Seizure Prophylaxis in Head Trauma
• Management of Elevated Intracranial Pressure

Prevent further brain injury

1. Head of bed @ 30 degrees
2. Prevent:
   1. Hypotension
   2. Hypoxia
   3. Anemia
   4. Hyperthermia
   5. Coagulopathy
3. Seizure Prophylaxis in Head Trauma

Increased ICP

1. Ensure adequate sedation (prevent gag reflex)
2. IVF to goal MAP >80 (maintains cerebral perfusion)
3. Mannitol
   1. If SBP>90
      1. If SBP>90 in adults use hypertonic saline NaCl 5% 150ml over 10 min
   2. Reduces ICP w/in 30min; duration of action of 6-8hr
   3. Bolus 20% @ 0.25-1 gm/kg as rapid infusion
   4. Monitor I+O to maintain euvolemia
4. Hyperventilation
   1. No longer recommended as prophylactic intervention
      1. Hyperventilation to PaCO2 <25 never indicated
   2. Brief course only recommended if impending herniation (i.e., Cushing reflex)
      1. 1. Maintain PaCO2 28-35 (20 breaths/min)
5. Seizure
   1. Treat immediately
   2. Seizure prophylaxis reduces sz but does not improve long-term outcomes
6. Goal CPP ~60mmHg
   1. If MAP <80, then CPP<60
      1. consider crystalloids or colloids (plasma if INR>1.3)
      2. phenylephrine 10-100mcg/min, or other pressors prn
      3. transfuse PRBCs, Hb>7

Elevating head of bed

• 30 degree elevation will help decrease ICP by increasing venous outflow

Seizure Prophylaxis and Treatment

• Prophylactic antiepileptics not recommended
• Continuous EEG monitoring probably indicated in ICH patients with depressed mental status that is out of proportion fo degree of brain injury
• Antiepileptics indicated for clinical seizures or seizures on EEG in patients with altered mental status

Blood Pressure

• Rapid SBP lowering <140 has been advocated with early research showing improved functional outcome, but more recent work has found no difference between SBP <140 and <180
• SBP >200 or MAP >150
  • Consider aggressive reduction w/ continuous IV infusion
• SBP >180 or MAP >130 and evidence or suspicion of elevated ICP
  • Consider reducing BP using intermittent or continuous IV meds to keep CPP >60-80
• SBP >180 or MAP >130 and NO evidence or suspicion of elevated ICP
  • Consider modest reduction of BP (e.g. MAP of 110 or target BP of 160/90)

• Nicardipine in ICH: Start at 5mg/hr, increase 2.5mg q5min until the target blood pressure is achieved and then immediately titrate down to maintenance infusion of 3mg/hr.
• Labetalol in ICH: 20mg bolus over 1-2 minutes, repeat q3-5 mins until target blood pressure is achieved and then start an infusion of 1-8mg/min.

Reverse coagulopathy

Example traumatic ICH coagulopathy reversal algorithm.

• See anticoagulant reversal for life-threatening bleeds if on a known anticoagulant (e.g. heparin, coumadin, rivaroxaban)
• Tranexamic acid 1g (if within 3 hours of event), followed by an additional 1g infused over 8 hours

Antiplatelet Reversal

Includes aspirin, prasugrel, clopidogrel

• Consider desmopressin (0.3mcg/kg)
• Platelet transfusion
  • No known thrombocytopenia: increases mortality; do NOT give
  • Known or diagnosed thrombocytopenia: consider if platelets <50,000
    • Some hematologists and neurosurgeons recommend for <100,000, despite lack of evidence for improved outcomes

See Also

• Head trauma (main)