Management of Traumatic Intracranial Hemorrhage in the Emergency Department (Trauma CME)

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Publication Date: February 2024 (Volume 27, Number 2)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 02/01/2028.

Specialty CME Credits:Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional approval.

Authors

Peer Reviewers

Abstract

Although there is a large body of existing research on traumatic intracranial hemorrhage, there are few clear and consistent recommendations that have emerged. Appropriate management is guided by an understanding of the pathophysiology of traumatic brain injury as well as by clinical observation and radiographic assessment. This review provides a comprehensive analysis of the literature and recommendations based on the best available evidence, including expeditious management of critically elevated intracranial pressure and acquisition of follow-up studies.

Case Presentations

A 24-year-old man with no past medical history presents by EMS following an unhelmeted all-terrain vehicle rollover accident…

• He has a temperature of 37.5°C, heart rate of 76 beats/min, blood pressure of 100/60 mm Hg, and respiratory rate of 17 breaths/min. His GCS score is 12 (E2V4M6).
• Computed tomography (CT) of the head, neck, chest, abdomen, and pelvis shows that he has bifrontal contusions, a skull fracture crossing midline, and a pelvic fracture.
• Two hours later, while consulting services are still pending recommendations, he becomes agitated and his GCS score has declined to 10 (E2V3M5). What treatments should you initiate and what additional imaging should you obtain?

An 85-year-old woman presents after a ground-level fall…

• She has a temperature of 37.6°C, heart rate of 65 beats/min, blood pressure of 124/69 mm Hg, and respiratory rate of 15 breaths/min. Her GCS score is 14 (E4V4M6).
• Her past medical history is notable for heart failure (ejection fraction 40%), chronic hyponatremia, atrial fibrillation on warfarin (INR 2.8), and dementia.
• CT reveals an 8-mm acute-on-chronic convexity subdural hematoma with 2-mm midline shift. Should you treat for elevated intracranial pressure, and should you give reversal for her anticoagulant? What treatments would you prioritize?

A 55-year-old woman with no past medical history is found unconscious by EMS after a single-car accident without airbag deployment…

• She has a temperature of 36.8°C, heart rate of 81 beats/min, blood pressure of 115/74 mm Hg, and respiratory rate of 18 breaths/min. She has no apparent injuries, and her GCS score is 13 (E3V4M6).
• CT shows subarachnoid hemorrhage extending deep into Sylvian fissure and a small volume of intraventricular hemorrhage. She does not remember the accident or what caused it. What imaging should you obtain next?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.