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3/25/2018 0 Comments

INcreased ICP

Increased Intracranial Pressure
Russell Trigonis PGY-2, Katie Lupez PGY-2, and Chris Gardner PGY-1
 
  • Increased intracranial pressures (ICP) can have many different causes with traumatic brain injuries (TBI) being one of the most common ones we see in the ED
  • Intracranial pressure, mean arterial pressure (MAP), and cerebral perfusion pressure (CPP) are linked according to following formula
CPP = MAP - ICP
 
  • In situations where intracranial pressure is elevated by a factor like a traumatic bleed, cerebral perfusion pressure will if the MAP remains constant. If the MAP drops too, the CPP can decrease to a critical level at which point the brain becomes ischemic
  • Increased intracranial pressure can be suspected with changes in GCS, localizing symptoms, or hemodynamic changes like bradycardia and hypertension (Cushings reflex)
  • If you suspect increased ICP, evaluate them quickly focusing on the ABCDs with a good neuro exam
  • If GCS < 8 or appears to be declining quickly, intubate to protect the airway
 
  • Consider ketamine and rocuronium for intubation
    • Ketamine has been proven safe in patients with increased ICP and shows no additional increase in ICP when used for RSI followed by mechanical ventilation
    • Rocuronium has been associated with improved mortality compared to succinylcholine in TBI patients
  • Make first attempt best attempt for intubation. Use video laryngoscopy if available as your first line agent to allow proper immobilization of C-spine as well as better first pass success.
 
  • Passive techniques to allow maximal venous and CSF drainage to minimize ICP
    • Elevated head-of-bed or reverse Trendelenburg positioning (30 degrees)
    • Properly fitted and positioned c-collar
    • Low mean airway pressures
 
  • Active techniques to decrease ICP
    • Consider sedation and paralytics only if patient requires it (cough, agitation). Otherwise these agents can cause hypotension or minimize your ability to perform serial neurological exams]
    • Hypertonic saline (3% NaCl) with a bolus of 150 – 250cc in adults may be more beneficial than mannitol (1-3 g/kg) to avoid AKI and hypovolemia
    • Can also consider 2 Amps of Sodium Bicarbonate (100cc of ~6% hypertonic solution)
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