Elevated ICP And Herniation

Question 1

What are the standard interventions to prevent herniation? (ENLS - Tier Zero)

Answer 1

1. Assess ABCs - assess airway patency, ventilation, and adequate circulation
2. Minimize noxious stimuli such as tracheal suctioning that may elevate ICP
3. Analgesia/sedation
4. Target normothermia
5. The head of the bed should be elevated to > 30°
6. Head and neck kept midline to facilitate cerebral venous drainage
7. Only iso or hyperosmotic fluids should be used as intravenous (IV) solutions
8. Avoid and correct hyponatremia (serum Na < 135 mmol/L)
9. High-dose corticosteroid therapy is initiated for vasogenic edema resulting from brain tumors, abscesses, or non-infectious neuroinflammatory conditions but should otherwise be avoided
10. If the brain has not yet been imaged, a non-contrast head CT scan should be performed when the patient can be positioned safely for diagnostic imaging.

Question 2

The patient is showing signs of herniation. Which Tier One interventions will you implement?
(ENLS - Tier One)

Answer 2

1. Hyperosmolar therapy - mannitol 0.5 - 1 g/kg over 5 - 15 minutes
2. Hyperosmolar therapy - HTS 2 - 23.4%, as a bolus, alone or in addition to mannitol, common therapy HTS 3% 3 - 5 ml/ kg, 20 ml/min.
3. A brief course (< 2 hours) of hyperventilation to a PaCO2 of 30-35 mmHg may be considered, until definitive treatment is provided.

Question 3

The patient continues to show signs of herniation as the Tier One interventions have failed to control
ICP. Which Tier Two interventions should be engaged? (ENLS Tier Two)

Answer 3

1. If hyperosmolar therapy with HTS has been administered, serum sodium goals may be increased if they are not yet at a maximal concentration (160 mmol/L) using intermittent 3% HTS boluses or a 3% HTS infusion.
2. Optimize sedation and analgesia. Sedation may be increased to aid in ICP management.

Question 4

The patient continues to show signs of herniation as the Tier Two interventions have failed to control
ICP. Which Tier Three intervention can we effectively implement in our environment? (ENLS Tier Three)

Answer 4

Hyperventilation to achieve mild-to-moderate hypocapnia (PaCO2 25-34 mmHg) may be considered in selected patients who have failed other management in the acute period.

Question 5

What is your MAP goal for a patient with elevated IP or signs of herniation?

Answer 5

MAP > 80 mmHg.
Normal CPP = 60 - 80 mmHg
Normal ICP = 5 - 10 mmHg
Elevated ICP or Herniation = ICP > 20 mmHg (if you are unable to measure the ICP you must assume the ICP is > 20 mmHg)

Question 6

What is the difference (gradient) between EtCO2 and PaCO2?

Answer 6

The gradient between EtCO2 and PaCO2 should be 2-5 mmHg. However, the gradient may be increased by respiratory dead space or low pulmonary perfusion (ventilation/perfusion or VI Q mismatch).