Page 1176 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

814 PART 6: Neurologic Disorders

B) Advanced ICP treatment approach Level 1: Temporary ICP elevation and crisis Check EVD (waveform, level, drainage); drain 3-5 mL of CSF Temporary increase in sedation 20% mannitol 1 g/kg IV bolus ×1 over 15-30 minutes OR 23.4% saline solution 30 mL IVP ×1 over 5 minutes Short-term paralysis Level 2: Recurrent or persistent ICP elevation Carefully reassess the patient as in Step 1 Repeat head CT Deepen sedation; switch to midazolam 0.02-0.2 mg/kg/h IV bolus of 20% mannitol 1 g/kg × 1 then 0.5 g/kg × 4-6 h; adjust serum osmolality to target 320-340 mOsm/L Neuromuscular paralysis vecuronium 0.8-1.4 g/kg/min IV infusion

Imaging evidence (see Table 4): diffuse brain edema; mass lesion with brain shift, hydrocephalus, etc
Suggestive on examination (see Tables 4 and 5): herniation signs, unreactive pupil, posturing, etc

Step 1: Recognizing intracranial hypertension

ICP likely elevated Suspected clinically and/or on imaging Step 2: Stabilization phase Head elevated at 30°C-45°C and straight; neck without tight wrapping Mannitol 1 g/kg IV bolus (or 23.4% saline 30 mL IV bolus) Preparation for immediate head CT (often also CTA and neck CT) Initiate volume resuscitation (normal saline/colloids/blood products) Stabilize blood pressure to MAP >80 mm Hg (fluids/pressors) Stabilize airway, oxygenate, and maintain O 2 sat >90% Intubate if needed; avoid hypoxemia, hypoventilation, and flat-on-bed time periods Propofol: 25-50 mg IV bolus for induction every 10 seconds then d
High-risk conditions (see Table 86-7): coma, TBI, infection

A) ICP Identification and stabilization phase

Decompression: Focused serial neurological examinations Circulation: Airway/breathing: Cervical spine precaution if needed Rapid screening neurological examination Induction medication (example): If needed, vecuronium 0.1 mg/kg IV decompression craniectomy) 2. Brain monitoring: 4) cerebral blood flow; 5) microdialysis

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