Escalator of ICP Management

P1 (Percussion)
P2 (Tidal)
P3 (Dicrotic)
arterial pulsation
intracranial compliance (elastance)
aortic valve closure
normally has the highest upstroke
early sign of high ICP is decreased compliance (hence higher wave)
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notion image
notion image

Conservative Measures

  • Check that EVD is working
  • HOB > 30, can go up to 90 degrees
  • Avoid hypotension
  • Cool the patient to 32-33
  • Escalate sedation (prop / fentanyl boluses)
  • Make sure not wearing a C-collar unnecessarily (can compress jugular venous outflow)

Osmotic Diuresis Therapy

  • Don't push sodium past 160 or osm past 320
  • Mannitol 0.5-1g/kg
    • Not great for severe TBI, good for SAH
    • mannitol also acts as free radical scavenger and decreases blood viscosity, transiently ↑ CBF
    • Consider mostly in adults > children
  • HTS 6.5 - 10 mL
    • Need to know most recent sodium then get q6

Paralyze

  • ROC 50 or 100 and make sure get TOF with zero twitches
  • Cis drip

Phenobarb (PHB) coma

  • we do not like to do (takes a long time to leave system); most people will sooner consider a trip to OR
  • physiology of why PHB helps:
    • decreased cerebral metabolic rate 2/2 decreased synaptic transmission
    • promotes hypothermia
    • increases intracerebral glucose/glucagon/phosphocreatine energy stores
    • decrease nitrogen excretion
    • shunts blood from normal --> hypoperfused regions
    • endogenous anticonvulsant
    • stabilizes lysosomal membranes
    • decreases excitatory NT and Ca2+
    • free radical scavenging (Thiopental)

Decompression

  • On the way to OR, hyperventilate with EtCO2 goal 25-35 (this is not a long-term strategy)
    • NOTE: PaCO2 < 25 (excessive hyperventilation) can cause ischemia