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***
ICP < 20
Seum Na < 150
Seum Osm < 320
CCP (= Map-ICP):  60-70
Core Body Temp. 32 - 34 C
PCO2 26-30
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.
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
(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)


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
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.