ICP Management


ICP (Intracranial pressure) CPP (Cerebral Perfusion Pressure) Managing Increased ICP 
  1. General measures
  2. First-tier therapies
  3. Second-tier therapies
  4. Alternative therapies (unproven/ controversial)


 

***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
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)


 

  TYPE OF PATIENT ANATOMIC LOCATION CT FINDINGS COMMON CAUSE CLASSIC SYMPTOMS
Epidural Most common in young adults, rare in the elderly Potential space between skull and dura mater Biconvex, football-shaped hematoma Skull fracture with tear  of the middle meningeal artery Immediate LOC with a "lucid" period prior to deterioration (only occurs in about 20% of patients)
Subdural More risk for the elderly & alcoholics Space between dura mater and arachnoid Crescent - or sickle-shaped hematoma Acceleration - deceleration with tearing of the bridging veins Acute: Rapid LOC - lucid period possible
Chronic: Altered MS & behavior with gradual decrease in consciousness
Subarachnoid Any age group following blunt trauma. Subarachnoid Blood in the basilar cisterns & hemispheric sulci & fissures Acceleration - Deceleration w/ tearing of the subarachnoid vessels Milt to moderate TBI w/ meningeal signs & symptoms
Contusion/
intracerebral hematoma
Any age group following blunt trauma. Usually anterior temporal or posterior frontal lobe May be normal initially with delayed bleed Severe or penetrating trauma, shaken-baby syndrome Symptoms range from normal to unconscious.
Abbreviations: LOC = loss of consciousness; MS = mental state; TBI = traumatic brain injury.