Management of Elevated Intracranial Pressure

• Elevated ICP present in:
• 3% of patients with GCS greater than 13
• 10% of patients with GCS 8-12
• 50% of paitents with GCS less than 8
• Monitor ICP if:
• GCS less than 8 and abnormal CT
• GCS less than 8, normal CT, and two of following:
• Age greater than 40
• Decerebrate
• Blood pressure less than 90
• GCS greater than 8 with mass lesion that cannot follow clinically
• Treatment of increased intracranial pressure
• Try to maintain ICP below 20 mm Hg and CPP above 50 mm Hg
• Remember: CPP = MAP -ICP
• Tape endotracheal tube instead of tying around neck
• Prevents increased venous pressure and thus increased ICP
• Elevate HOB
• Improves venous return
• Can be accomplished in patients with uncleared cervical spine by placing hospital bed into reverse Trendelenburg
• Minimize hydration -NO FREE WATER, maintenance IV only
• Minimizes fluid available to exacerbate cerebral edema
• Keep PCO₂ normal (35 to 40)
• There is mounting evidence that chronic hyperventilation causes further cerebral injury by vasoconstricting blood supply to already injured brain
• Acute hyperventilation as means to stabilize ICP on the way to the OR for decompression of a mass lesion or during occasional ICP plateau waves remains a valuable and acceptable tool
• Hyperventilation causes vasoconstriction, thus decreasing intravascular component of intracranial volume
• Paralyze and sedate patient
• Prevents tone/bucking ventilator which can elevate ICP
• Vecuronium 0.1 mg/kg/hr is usually sufficient
• Morphine and Versed for sedation
• Must hold all medications once each day to check neuro exam
• Osmotic agents
• Causes osmotic removal of water from extracellular space to intravascular space with subsequent diuresis
• Mannitol as bolus – use smallest dose to achieve response
• Usually 12.5- 25 g in adults, 6.25 g in children
• Must monitor electrolytes and serum osmo closely (q4° or q6°)
• Do not push serum osmo > 320 or renal toxicity may occur
• Occasionally, the addition of lasix 20-30 min after mannitol administration will assist with the diuresis
• Ventricular drainage
• Decreases CSF component to intracranial volume
• Pentobarbital coma
• Decreases cerebral metabolic demand
• Used when all else fails
• Load Pentobarb 5 mg/kg, then use 1-3 mg/kg/hr till ICP has stabilized, burst suppression attained by EEG, or level 3 to 4 mg%
• J Neurosurg 69: 15, 1988.
• Once given, takes long to pass from system and can make clinical brain death difficult to establish
• Consider earlier use in young patients with difficult to control ICP
• Induced hypertension
• Rarely, vasopressors may be added in attempt to elevate MAP to maintain adequate cerebral perfusion
• Generally, ICP rises in conjunction with MAP resulting in no overall advantage
• Decompressive craniotomy
• Rarely used method using large craniectomy to decompress
• Bone is stored for later cranioplasty if patient survives