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Management of raised intracranial pressure

Created: 30/12/2006
Updated: 30/12/2006

ABC approach

Intubate, if not already done so.
Cervical spine protection (trauma patients) with in-line immobilization.
Avoid tight ETT ties as this will hamper venous drainage

IPPV with hyperventilation to arterial PaCO2 4 - 4.5 kPa.
Maintain SpO2 > 96% and PaO2 > 12 kPa
Avoid coughing with sufficient sedation and muscle relaxation

Hypotension is the biggest cause of secondary brain injury and should be treated aggressively.

Maintain CPP > 70 mmHg (MAP > 90), with fluid initially and commence vasopressors if necessary.

Invasive arterial blood pressure and central venous pressure monitoring.

Urinary catheter to monitor urine output and especially if mannitol is used.

Adequate sedation, propofol infusion
Muscle relaxation
Mannitol 0.25 – 0.5 g/kg
Hypertonic saline (NaCl 3%) 1 – 2 ml/kg
Thiopentone may be considered in severe cases
Paracetamol for raised temperature

Maintain normothermia and especially avoid hyperthermia as this will increase the CMRO2. Mild hypothermia may be protective, but extreme levels will exacerbate a coagulopathy and bleeding. A 30o head-up position will improve venous drainage.

Maintenance fluids should be given judiciously, so as not to exacerbate cerebral oedema. Isotonic saline is preferred to glucose containing solutions, aiming to keep the serum sodium above 135 mmol/l.

Maintain normoglycaemia with insulin if necessary.

Ensure that haemoglobin is adequate to optimize the oxygen content of blood. Correct any coagulopathy in event of intracranial bleeding.

Urgent CT scan for neurosurgical review. Routine blood tests including, FBC, clotting studies, U&Es, arterial blood gas and cross-match blood for theatre.

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