Management of increased intracranial pressure in the emergency department
1. head elevation (~30 degreees) (or bed-tilt if patient on spinal precautions)
2. avoid any constrictions on the neck (on the jugular veins) (e.g. replace hard collars as soon as practicable with sand bags; avoid tightening ETT tie over the neck; maintain head in the midline)
3. maintain MAP (mean arterial pressure) > 85 mmHg (in the absence of ICP monitor) with iv fluids and vasopressors if needed
4. sedation – they need deep sedation, be particularly careful to increase sedation rather than paralyse when they show signs of “waking up”; consider using barbiturates as there is some evidence they lower the cerebral metabolism (thiopentone in Australia)
5. neuromuscular blockade
6. mannitol 0.25 – 1 g/kg – osmotic diuretic, make sure they have adequate hydration
7. hypertonic saline 3% 0.1 – 1 ml/kg
8. ventilate to maintain normal paO2 and paCO2 i.e. avoid hypercapnia, hypoxia and hyperoxia
9. hyperventilation to paCO2 30 – 35 mmHg only as a temporizing measure in patients with acute increase in ICP who are going to theatre for decompressive craniotomy
10. treat seizures BUT prophylactic treatment not universally agreed on
11. keep temperature < 37 degrees Celsius – potential benefit from mild hypothermia (35 degrees Celsius) being investigated at the moment (the POLAR study)
12. decompressive craniotomy / burr holes – rarely done in ED but, if there is delay to theatre, the Neurosurgeons might consider doing it in ED, or if you work in a remote area you might need to do burr holes to drain extradural or subdural haemorrhages (after discussion with the Neurosurgeons)
Great summary on managing ICP.
Looking forward to reading more post from EMergucate.
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