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)