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Increased Intracranial Pressure in Closed Head Injury
Aka: Increased Intracranial Pressure in Closed Head Injury, Increased Intracranial Pressure in Trauma, Severe Head Trauma Related Increased Intracranial Pressure
- See Also
- Brainstem Herniation
- Severe Head Injury Management
- Differential Diagnosis
- Increased Intracranial Pressure Causes
- Pathophysiology
- Closed Head Injury with secondary Increased Intracranial Pressure
- Signs: Findings indicating management below
- Intracranial Pressure >15 mm
- Severe Closed Head Injury (GCS 8 or less)
- Cerebral edema
- Cushing Response
- Severe Hypertension
- Severe Bradycardia
- Severe Hypopnea
- Diagnostics: Intracranial Pressure Monitoring
- Indications
- Glasgow Coma Scale 8 or less after Resuscitation (or <12 if abnormal CT Head) OR
- Criteria despite normal CT Head
- Age >40 years old
- Systolic Blood Pressure <90 mmHg
- Decerebrate or Decorticate motor posturing (unilateral or bilateral)
- Management
- See Severe Head Injury Management
- Transfer to Neurosurgery
- See Cerebral Herniation
- Improve cerebral venous drainage
- Head of bed elevated (20-35 degrees, up to 45 degrees)
- Promotes CNS venous drainage
- Avoid internal jugular compression
- Keep head midline
- Internal jugular line placement is Contraversial (some advocate subclavian lines instead)
- Avoid tight Cervical Collars
- Switch to better fitting collar (e.g. Aspen) if C-spine cannot be cleared with exam and imaging
- Maintain adequate Cerebral Perfusion Pressure (MAP - ICP)
- Maintain MAP>65-80 mmHg (and ideally ICP <20)
- Keep systolic Blood Pressure <140-160 mmHg (higher BPs raise Intracranial Pressure)
- Nicardipine (or Clevidipine) is preferred
- Avoid Nitroglycerin and Nitroprusside (if possible) to maintain adequate Preload
- Avoid Labetalol (if possible) to maintain adequate cardiac contractility
- Airway and Rapid Sequence Intubation Management
- Consider Delayed Sequence Intubation to avoid peri-intubation Hypoxia
- Etomidate is a preferred RSI induction agent in Head Injury
- Ketamine is a safe and effective RSI induction agent without risk of ICP increase
- Zeiler (2014) J Crit Care 29(6): 1096-106 +PMID:24996763 [PubMed]
- Cohen (2015) Ann Emerg Med 65(1): 43-51 +PMID:25064742 [PubMed]
- Premedications are not typically indicated
- Pre-Intubation Lidocaine has been debunked and offers no benefit in ICP (see Rapid Sequence Intubation)
- Fentanyl 4-5 mcg/kg may decrease ICP, but also risks Hypotension
- Sedation
- Propofol may be preferred (lowers cerebral metabolic rate)
- Start Propofol at 20 mcg/kg/min and titrate
- Limit Propofol boluses as much as possible to avoid Blood Pressure fluctuations
- If boluses are needed, use small, 20 mg IV boluses at a time
- Ventilation
- PEEP does not increase intracranial presssure (increase as needed)
- Avoid hyperoxygenation
- Goal Oxygen Saturation >90% and preferred at 94-97%
- Avoid Hyperventilation
- Normocapnia is preferred (pCO2 35 to 38 mmHg)
- Hyperventilation is generally no longer recommended
- Vasoconstricts (reducing ICP transiently) but also decreasing cerebral perfusion
- Some intensivists mildly hyperventilate with goal pCO2 30-35 mmHg
- Old guidelines hyperventilated to pCO2 25-30 mmHg
- Acutely lowering Intracranial Pressure (e.g. impending Brainstem Herniation)
- Mannitol 20%
- Adult: 1 g/kg IV (50-100 g) bolus over 5 minutes
- Child: 0.25 to 0.5 g/kg IV bolus over 5 minutes
- Observe closely for Hypotension (and avoid if hypotensive)
- Monitor Urine Output
- Hold manitol for Hypotension, Hypernatremia with Sodium >152 or Serum Osms >305
- Other measures to consider
- Phenobarbital Infusion
- Mansour (2013) J Neurosurg Pediatr 12(1):37-43 [PubMed]
- Hypertonic Saline (controversial)
- Dosing: 100 cc of 3% Saline
- Does not improve Intracranial Pressure or benefit mortality in Severe Closed Head Injury
- Berger-Pelleiter (2016) CJEM 18(2): 112-20 +PMID:26988719 [PubMed]
- Others still recommend Hypertonic Saline (consider for signs Brainstem Herniation)
- Expert opinion that Hypertonic Saline and manitol have equivalent efficacy
- Hypertonic Saline is safe, even in Hyponatremia, and without Hypotension risk
- Orman and Weingart in Herbert (2017) EM:Rap 17(6):8-9
- Other measures that are no longer recommended (debunked)
- Avoid Hyperventilation (see above)
- Definitive management with Neurosurgery
- See Skull Trephination (if imminent Brainstem Herniation)
- Ventriculostomy or
- Surgical decompression
- Precautions
- Sustained ICP > 20 mmHg is associated with worse outcomes (ischemia risk)
- Maintain adequate Cerebral Perfusion Pressure
- References
- Orman and Weingart in Herbert (2017) EM:Rap 17(1): 5-6