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

Table of Contents

 

About This Issue

For patients who present to the ED with head injury, the determining whether and what kind of intracranial bleeding may be occurring is critical, in order to properly manage hemodynamics, prevent critical elevation of intracranial pressure, and potential decompensation and brain death. In this issue, you will learn:

Clues for determining whether the bleed is spontaneous or traumatic

The types of traumatic intracranial hemorrhage (ICH), their pathophysiology, imaging clues, and likely outcomes

How to determine a patient’s risk level for critical intracranial pressure: age, mechanism of injury, GCS score imaging findings

When to order repeat CT imaging, CT venogram, CT angiogram, and magnetic resonance imaging

How and when to execute the essential treatments: managing coagulopathy, hemodynamics, intracranial pressure, airway, and seizure

When surgical intervention is appropriate

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
   1. Traumatic Subarachnoid Hemorrhage
   2. Subdural Hematoma
   3. Epidural Hematoma
   4. Intraparenchymal Hemorrhage
   5. Skull Fractures
   6. Penetrating Trauma
   7. Intraventricular Hemorrhage
7. Differential Diagnosis
   1. Assessing Consciousness
   2. Determining Spontaneous Versus Traumatic Causes of Intracranial Hemorrhage
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
      1. Neurological Examination
         1. Asymmetry of Examination
         2. Alertness
         3. Evidence of Skull Base Injury
         4. Cushing Triad
         5. Brainstem Function
            • Neuromuscular Response
            • Pupillary Responses
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging and Other Studies
       1. Computed Tomography
          1. Repeat Noncontrast Head Computed Tomography
          2. Computed Tomographic Venogram
          3. Computed Tomographic Angiogram
       2. Optic Nerve Sheath Diameter Ultrasound
       3. Magnetic Resonance Imaging
       4. Electroencephalogram
11. Treatment
    1. Tier 1: First Interventions for a Patient With Concern for Elevated Intracranial Pressure
       1. Risk-Stratifying Head Injury
       2. Managing Coagulopathy
       3. Managing Hemodynamics
       4. Managing Intracranial Pressure
          1. Intravenous Fluids
          2. Positioning
          3. Managing Pain and Shivering
       5. Managing the Airway
       6. Managing Seizure
       7. Indications for Interventions
    2. Craniotomy
    3. Craniectomy
    4. Intracranial Pressure Monitor
    5. Burr-Hole Craniostomy
    6. External Ventricular Drainage
    7. Contraindicated Treatments
    8. Tier 2: Second Set of Interventions for a Patient With Persistent Concern for Elevated Intracranial Pressure
    9. Tier 3: Third Set of Interventions for a Patient With Persistent Concern for Elevated Intracranial Pressure
12. Special Populations
13. Controversies and Cutting Edge
14. Disposition
15. Risk Management Pitfalls in Emergency Department Management of Traumatic Intracranial Hemorrhage
16. 5 Things That Will Change Your Practice
17. Summary
18. Time- and Cost-Effective Strategies
19. Case Conclusions
20. Clinical Pathways
    1. Clinical Pathway for Patients With Newly Discovered Traumatic Intracranial Hemorrhage
    2. Clinical Pathway for Stepwise Treatment of Elevated Intracranial Pressure
21. Tables and Figures
22. References

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?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

EB Medicine is excited to add a new subscriber benefit, EMP: IRrL (In Rural Life) with real-time utility for EM clinicians, especially those practicing in rural settings. This supplemental content will focus on challenges and solutions when the pressure is on and resources are limited. Learn more about EMP: IRrL here.

Clinical Pathway for Patients With Newly Discovered Traumatic Intracranial Hemorrhage

Subscribe to access the complete Clinical Pathway to guide your clinical decision making.

Tables and Figures

Subscribe for full access to all Tables and Figures.

Key References

Following are the most informative references cited in this paper, as determined by the authors.

4. * Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery. 2017;80(1):6-15. (Brain Trauma Foundation consensus guidelines) DOI: 10.1227/NEU.0000000000001432

23. * Pace J, Parry N, Vogt K, et al. A clinical prediction model for raised intracranial pressure in patients with traumatic brain injuries. J Trauma Acute Care Surg. 2018;85(2):380-386. (Retrospective cohort; 580 patients) DOI: 10.1097/TA.0000000000001965

30. * Lulla A, Lumba-Brown A, Totten AM, et al. Prehospital guidelines for the management of traumatic brain injury - 3rd edition. Prehosp Emerg Care. 2023;27(5):507-538. (Brain Trauma Foundation consensus guidelines for prehospital providers) DOI: 10.1080/10903127.2023.2187905

41. * American College of Surgeons Expert Panel. Best practice guidelines: the management of traumatic brain injury. ACS Brief. 2024. Accessed January 10, 2025. (Expert panel guidelines)

49. * Joseph B, Friese RS, Sadoun M, et al. The BIG (Brain Injury Guidelines) project: defining the management of traumatic brain injury by acute care surgeons. J Trauma Acute Care Surg. 2014;76(4):965-969. (Retrospective cohort; 3801 patients) DOI: 10.1097/TA.0000000000000161

54. * Hawryluk GWJ, Aguilera S, Buki A, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2019;45(12):1783-1794. (Consensus-based algorithms) DOI: 10.1007/s00134-019-05805-9

55. * Joseph B, Obaid O, Dultz L, et al. Validating the Brain Injury Guidelines: results of an American Association for the Surgery of Trauma prospective multi-institutional trial. J Trauma Acute Care Surg. 2022;93(2):157-165. (Prospective, observational, multi-institutional trial; 2432 patients) DOI: 10.1097/TA.0000000000003554

65. * Cook AM, Morgan Jones G, Hawryluk GWJ, et al. Guidelines for the acute treatment of cerebral edema in neurocritical care patients. Neurocrit Care. 2020;32(3):647-666. (Consensus statement from the Neurocritical Care Society) DOI: 10.1007/s12028-020-00959-7

85. * Kannan S, Gillespie CS, Lee KS, et al. Diagnostic utility of Brain Injury Guidelines (BIG): systematic review and meta-analysis for prediction of neurosurgical intervention in traumatic brain injury. Brain Inj. 2024:1-8. (Systematic review and meta-analysis; 9032 patients) DOI: 10.1080/02699052.2024.2375593

Subscribe to get the full list of 85 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: traumatic, spontaneous, intracranial, hemorrhage, pressure, ICP, TBI, SAH, herniation, hematoma, intraparenchymal, GCS, asymmetry, CT, CTA, MRI, coagulopathy, blood pressure, airway