Cerebral Edema


***Unilateral Fixed Dilate Pupil in a pt after Stroke = Herniating brain***
GOAL:
 
ICP < 20
Seum Na < 150
Seum Osm < 320
CCP (= Map-ICP):  60-70
Core Body Temp. 32 - 34 C
PCO2 26-30
Management
Osmotic Therapy Mannitol: DOSE: 1g/kg bolus over 30 min., then repeat dose: 0.25 - 0.5 g/kg q4-6h prn. (e.g: Mannitol 25% 40g)
SE: Rebound ICP secondary to BBB damage.
Monitor:
Serum Na: Goal < 150
Serum Osm: Goal < 320, (between 295 - 305)
Renal function: Pt w/ RA/Kidney damage = bad candidate for mannitol
Hypertonic Saline 3% saline (250 cc) bolus
 
Acute: ICP
Chronic: outcome unclear
Glucocorticoids: DO NOT USE
Hyperventilation:
(for Max 24hr)
PCO2 = 26-30 Rapid ICP (1 mmHg : 3% change in CBF)
** Change Vent settings ( RR by 2) very slowly to bring up PCO2 ~ 35
MOA: ↓ PCO2 Vasoconstriction = Cerebral Blood Flow
Therapeutic Hypothermia Whole Body Cooling (Lavage, cooling blanket)
Goal: Core body temp. = 32-34 C
Re-warm over 24 hr
Deep Sedation Propofol, Versed, Fentanyl. NIMBEX (paralyze)
MOA: Brain metabolism & Blood flow ICP  (require accurate ICP monitoring)

 
ICP (Intracranial pressure)
  1. General principles
  2. Pathophysiology
  3. ICP Monitoring
CPP (Cerebral Perfusion Pressure)
  1. Defined as the difference between Mean Arterial Pressure (MAP) and ICP (intracranial pressure)
  2. CPP represents the pressure gradient driving cerebral blood flow
  3. Maintenance of adequate CPP is a cornerstone of brain injury treatment
  4. Critical threshold is 50-70 mmHg
  5. CPP can be maintained by
  6. Generally, ICP is maintained at < 20 mmHg, and MAP is raised therapeutically
  7. IMPORTANT
Managing Increased ICP 
  1. General measures
  2. First-tier therapies
  3. Second-tier therapies
  4. Alternative therapies (unproven/ controversial)