Episode 84.0 – Traumatic ICH Management

This week we look at TBI and discuss some of the pitfalls and pearls in early management of traumatic ICH.

February 13th, 2017 Download 2 Comments Tags: , , , , , ,

Show Notes

Take Home Points

  1. If you get a heads up from EMS on an incoming trauma, take the lead time you get to clearly delineate everyone’s roles to help ensure the resuscitation runs smoothly.
  2. In the severe TBI patient, the key is in preventing secondary injury to the brain. We do this by guarding against hypoxia, hypercarbia, hypotension and aspiration. Max your pre-ox, get the ETT in quickly to prevent oxygenation and ventilation issues and keep the head up if possible
  3. Hypotension is rarely seen in isolated head trauma. If the patient is or becomes hypotensive, reassess for any sources of hemorrhagic shock that may have been missed and consider whether the meds you gave may have caused the problem.
  4. Hypertension is much more common and despite extensive research, we haven’t shown that dropping the patient to normal levels is beneficial. Keeping the SBP < 180 seems reasonable but check your local protocol as well.
  5. If the patient’s ICP spikes or your concerned about herniation, administer mannitol or hypertonic saline and get your neurosurgeon to the bedside since the patient is gonna need decompression
  6. Finally, make sure to reverse any anticoagulant the patient may have on board as this will hopefully prevent hematoma expansion.

Read More

emDocs: Roc Rocks and Sux Sucks! Why Rocuronium is the Agent of Choice for RSI

Core EM: Podcast 31.0 – Rocuronium vs. Succinylcholine

Core EM: Intensive Blood Pressure Lowering in Intracerebral Hemorrhage (ATACH-2 Trial)

PulmCCM: Hyperosmolar Therapy for Increased Intracranial Pressure (Review)

EM Cases: Episode 89 – DOACs Part 2: Bleeding and Reversal Agents

Hopper AH. Hyperosmolar therapy for raised intracranial pressure. NEJM 2012; 367(8): 746-52. PMID: 22913684

Wang X et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 2014; 28(6): 821-7. PMID: 24859931

Zeiler FA et al. The ketamine effect on ICP in traumatic brain injury. Neurocrit Care 2014; 21(1): 163-73. PMID: 24515638


  • Michael Herman says:

    Hello Dr. Swaminathan,

    Just a comment regarding your reference to ATACH 2 and INTERACT 2. Both of these trials look at spontaneous ICH, not traumatic ICH which is being discussed here. Given the underlying etiology of spontaneous ICH is almost always uncontrolled chronic hypertension, it makes sense that rapid lowering of BP in someone who has chronic hypertension would not improve outcomes. I don’t think its necessarily appropriate to extrapolate this data for the traumatic ICH population.

    • Anand Swaminathan, MD says:

      That’s a great point and I shouldn’t have generalized those studies to the traumatic patient. Most traumatic ICH improves with pain control but, occasionally, hypertension persists. I’m still not sure what our goal should be in these patients. Thanks for the comments!

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