Template:Increased ICP treatment

Increased ICP Treatment

Treatment guidelines from the [Brain Trauma Foundation[1]

Head of Bed elevation

  • 30 degrees or reverse Trendelenburg will lower ICP[2]

Maintain cerebral perfusion

  • Provide fluids and vasopressors if needed for goal cerebral perfusion pressure (CPP) of 80mm Hg[3][4]
  • Transfuse PRBCs with goal Hb>7
  • CPP = MAP-ICP
    • If MAP <80, then CPP<60

Osmotherapies

Therapies include ither 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
    • Bolus 20% @ 0.25-1 gm/kg as rapid infusion (target Osm 300-320 mOsm/kg)
    • Reduces ICP within 30min; duration of action of 6-8hr
    • Monitor I+O to maintain euvolemia
  2. Hypertonic Saline
    • Most studies used 250 mL bolus of 7.5% saline with dextran[5]
    • target sodium 145-155mg/dL
    • Higher osmotic gradient and less permeable across BBB than mannitol

Prevent Cerebral Constriction

  • Hyperventilation is not recommended
  • Hyperventilation to PaCO2 <25 never indicated
  • Maintain PaCO2 35-40mmHg

Seizure Control

  • Treat immediately with benzodiazepines and antiepileptics
  • Seizure prophylaxis reduces seizures but does not improve long-term outcomes

Intubation Pretreatment

Goal cerebral perfusion pressure (CPP) ~60mmHg

  • If need for RSI, consider pretreatment with lidocaine and/or fentanyl
  • Also ensure adequate sedation (prevent gag reflex)

Decrease metabolic rate

  • Provide adequate sedation and analgesia
  • Avoid hyperthermia
  1. ↑ Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1(supplement 1):S1-S106.fulltext
  2. ↑ Schwarz S et al. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke. 2002; 33: 497-501
  3. ↑ Bouma GJ et al. Blood pressure and intracranial pressure-volume dynamics in severe head injury: relationship with cerebral blood flow. J Neurosurg 77:15-19, 1992
  4. ↑ Rosner MJ et al. Cerebral perfusion pressure management in head injury. J Trauma 30:933-941, 1990
  5. ↑ Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013
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