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)