Increased intracranial pressure

Clinical Manifestations

• Headache
• Nausea/vomiting
• Cushing response
  • Hypertension
  • Bradycardia
  • Irregular respiration

Management

• Invasive monitoring of ICP
  • Indications
    • At risk for elevated ICP
    • Comatose
    • Prognosis not hopeless
  • Contraindications
    • Bleeding diathesis or anticoagulation
  • Risks
    • Intracranial hemorrhage (1-2%)
  • Devices
    • Intraventricular catheters
    • Parenchymal monitors
    • Extra-axial devices
    • Non-invasic TCD of JvO2
  • Aim for ICP < 20 while maintaining cerebral perfusion pressure > 70
    • Based on extra-auditory meatus
• Decrease intracerebral contents
  • Vascular
    • Elevate head of bed
    • Hyperventilation to pCO2 30-40 (though can go lower acutely)
  • CSF
    • Reduce CSF production with furosemide or acetazolamide
    • CSF drainage
  • Parenchyma
    • Remove the mass or create space
    • Osmotic diuresis with mannitol and 3% saline
  • Brain volume
    • Hypertonic saline 3% 5ml/kg
    • Mannitol 1g/kg
• Increase skull capacity
  • Craniectomy or decompression
• Decrease oxygen demand
  • Deep sedation with propofol or barbiturates
  • Hypothermia
  • Paralysis (decreases systemic demand meaning more oxygen available to the brain)