Page 1178 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

CHAPTER 86: Intracranial Pressure: Monitoring and Management 815

Protect and secure airways Spine precautions in trauma patients Avoid hypoxia; goal Pa O 2 >80 mm Hg Goal O 2 sat >90% Keep Pa CO 2 35-38 mm Hg No prolonged hyperventilation Hyperventilation may be used for ICP crises or pending herniation Avoid hypercapnia (vasoconstriction may produce ischemia) Do ABGs and use end tidal CO 2 Do chest x-ray Early feeding (within 24 hours) Maximize caloric feeding for critically ill patients Prokinetic medications, if with ileus Aim for normothermia (Brain temp <37°C) Prevent shivering If febrile and with EVD, examine CSF Normalize bleeding parameters (eg, platel

IV. Pulmonary V. Gastroenterology Laxative VI. Infectious Disease VII. Hematology VIII. Endocrinology IX. Pain Algorithm for treatment of intracranial hypertension. Constant evaluation of neurological, hemodynamic, and respiratory status is vital in the management of increased intracranial pressure. Imaging of the brain at any point in the algorithm may be done as indicated. General measures in a systematic manner that includes the medical and surgical management goals are summarized. There should be a careful and frequent reassessment in any patient with labile ICP. AED, anti

Step 5: Neurocritical care approach If with seizures, may use ativan or diazepam IV then fosphenytoin Clinical deterioration, GCS change within less than 48 hours after injury Correlate exam, ICP monitor (check for malfunction, artifacts, etc), and imaging results Maximize decompressants (medical and surgical) as appropriate If still unable to attain target ICP despite the decompressants, proceed to protocol approach in applying pharmacologic coma (ie, propofol, pentobarbital, etc) First target serum Na 145-150 mg/dL then adjust as needed intracranial pressure; IVP, intravenous push; MAP, mean arteri

Clinical exam charted hourly Monitor for herniation signs (see Tables 4 and 5) Cervical spine clearance Avoid drugs that increases ICP (see Table 15) Detect, prevent and treat seizures; cvEEG x 48 hours Decide on prophylactic AED for 7-14 days If status epilepticus, proceed with protocol approach Repeat head CT, if ICP rising or remains elevated Neurosurgery service standby Avoid cerebral hypotension (CPP <60 mm Hg); Maintain head elevation at 30°-45° Keep neck straight; avoid tight neck wrapping Stabilize CPP at 60-70 mm Hg Control arrhythmias If no ICP monitoring, maintain MAP at 80-90 mm Hg

I. Neurologic II. Cardiovascular III. Renal

FIGURE 86-18.

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