Template:Increased ICP treatment

Increased ICP Treatment

Head of Bed elevation

• 30 degrees or reverse Trendelenburg will lower ICP
• Keep head and neck in neutral position, improving cerebral venous drainage
• Avoid compressing IVJ or EVJ with tight C-collars or fixation of ETT

Maintain cerebral perfusion

• CPP = MAP-ICP
  • If MAP <80, then CPP<60
  • Ultimately no Class 1 evidence for optimal CPP
• Transfuse PRBCs with goal Hb > 10 mg/dL in severe TBI
• Provide fluids and vasopressors if needed for goal cerebral perfusion pressure (CPP) of 70-80 mmHg
  • Mortality increases 20% for each 10 mmHg loss of CPP
  • Avoid dips in CPP < 70 mmHg, which is associated with cerebral ischemia and glutamate increase
• Vasopressors
  • Phenylephrine increases CPP without increasing ICP in animal models
  • May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)
  • Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI
• IV fluids
  • Maintain euvolemia, initially resuscitate with Normal Saline
  • Then consider hypertonic saline and/or mannitol
  • Do not use free water, low osmolal, dextrose-alone solutions, and colloids
  • Do not use Ringer's lactate as it is slightly hypotonic
  • Prefer NS over D5-NS if possible, but D5-NS may be necessary to avoid hypoglycemia, especially in younger pediatric patients
  • Correction of severe hypernatremia > 160 mmol/L (hypothalamic-pituitary injury, diabetes insipidus) should be gradual to not worsen cerebral edema

Osmotherapies

Therapies include either mannitol or hypertonic saline. In choosing the appropriate agent, coordinate with neurosurgery and take into account the patient's blood pressure. Mannitol may cause hypotension due to the osmotic diuresis.

1. Mannitol
   • If SBP > 90 mmHg
   • Bolus 20% at Mannitol 0.25-1 g/kg IV over 15-20 min IV — If SBP >90; target Osm 300-320
   • Target Osm 300-320 mOsm/kg
   • Reduces ICP within 30min, duration of action of 6-8hr
   • Monitor I/O to maintain euvolemia during expected diuresis and use normal saline to volume replace
   • Do not use continuous infusions, as mannitol crosses the BBB after prolonged administration and contributes to cerebral edema
     • Consider hypertonic saline for further boluses
     • Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol
2. Hypertonic saline may be more effective than mannitol, current standard of care
   • Obtain baseline serum osmolarity and sodium
   • Most studies used 250 mL bolus of 7.5% saline with dextran
   • Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
   • Target sodium 145-155 mmol/dL

Prevent Cerebral Vasoconstriction

• Hyperventilation does not improve mortality, used only as temporizing measure
• Should only be used if reduction in ICP necessary without any other means or ICP elevation refractory to all other treatments:
  • Sedation
  • Paralytics
  • CSF drainage
  • Hypertonic saline, osmotic diuretics
• Maintain PaCO₂ 35-40 mmHg for only up to 30 minutes, no longer if it can be avoided
• Hyperventilation to PaCO2 < 30 mmHg not indicated, and decreases cerebral blood flow to ischemic levels

Seizure Control

• Treat immediately with benzodiazepines and antiepileptic drugs (AEDs)
• Consider propofol for post-intubation sedation
• Seizure prophylaxis reduces seizures but does not improve long-term outcomes
  • AEDs prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review
  • Risk factors for post-traumatic seizures:
    • GCS < 10 initially
    • Cortical contusion
    • Depressed skull fracture
    • Subdural hematoma, epidural hematoma
    • Subarachnoid hemorrhage or ICH
    • Penetrating head injury
    • Seizure within 24 hours of injury (immediate seizure)
• Treat any clinically apparent and EEG confirmed seizures
  • Consider prophylaxis in patients with any risk factors as above
  • Phenytoin or fosphenytoin first line agent by BTF guidelines
    • Fosphenytoin 20 PE/kg IV load, then 100 PE IV q8hrs x 7 days IV
    • Measure serum levels to titrate to therapeutic levels
  • Levetiracetam may be used as alternative
    • Levetiracetam 20 mg/kg IV load, then 1000 mg IV q12h x 7 days IV
    • Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
    • In many EDs, levetiracetam is current first line therapy

Intubation Pretreatment

Goal cerebral perfusion pressure (CPP) ~70mmHg

• If need for RSI, consider pretreatment with lidocaine and/or fentanyl
  • May contribute to peri-intubation hypotension
• Also ensure adequate sedation (prevent gag reflex)
• Etomidate may cause adrenal insufficiency especially in head injured patients, so consider hydrocortisone if refractory hypotension post-intubation

Decrease metabolic rate

• Provide adequate sedation and analgesia
• Avoid HYPERthermia and treat fever aggressively
  • However, hypothermia is not a necessary goal
  • Moderate hypothermia 32°C to 34°C controversial, large RCT showed no effect

Other Critical Care Measures

• DVT prophylaxis with SCDs, no anticoagulation
• Stress ulcer prophylaxis with H2 blocker/PPI and sucralfate to avoid Cushing's ulcers
• Good glycemic control, but tight maintenance not supported
• Steroids, methylprednisolone contraindicated in severe TBI (risk of death increased in CRASH 2004 trial)
• Routine paralysis not indicated
  • Increased risk of pneumonia and ICU length of stay
  • However, may be used for refractory ICP elevation

Barbiturate Coma

• For ICP refractory to maximal medical and surgical therapy
• Only for hemodynamically stable patients
• Induce with the following:
  • Pentobarbital 10 mg/kg IV over 30 min, then 5 mg/kg/hr x3 hrs, then 1 mg/kg/hr IV
  • Then 5 mg/kg/hr for 3 hrs
  • Followed by 1 mg/kg/hr