Outline the techniques  you would use to control intra-cranial pressure in a patient  with a severe closed head injury.

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College Answer

Management priorities will be determined by the exact clinical scenario, though the general principles are consistent. Consider recommendations (eg. Brain Trauma Foundation).
•    Ensure simple reversible causes are not present (elevate head, maintain head in central position with no venous occluding tapes, adequate sedation, treatment of seizures, adequate volume status, adequate oxygenation, arterial carbon dioxide not elevated).
•    Consider exclusion of reversible mass lesion (CT or repeat CT).
•    Drain CSF from ventricle (if drain in situ).

Further techniques that could be considered at this point include: further decrease in arterial carbon dioxide (to 30-35 mmHg), mannitol (keeping euvolaemic and osmolarity < 320 mOsm/L), additional sedation (including barbiturates) ± paralysis (decrease straining against ETT/ventilation), hypertonic saline, induced hypothermia, decompressive craniectomy, (? hypertensive therapy, further hyperventilation).

Discussion

This question closely resembles Question 12 from the first paper of 2004.

Stereotypical steps in ICP management:

  • Position the head (45 °head up, facing straight)
  • Loosen the ETT ties
  • Remove the C-spine collar
  • Decrease PEEP as much as possible
  • Increase sedation
    • Propofol sedation to decrease distress and thus decrease ICP
    • Benzodiazepines may be of use (but they do not decrease the CMRO2 as much as propofol)
  • Drain some CSF from the EVD
  • Paralysis with neuromuscular junction blocker
  • Osmotherapy
    • Mannitol 20%
    • Hypertonic saline
  • Super-refractory ICP
    • Hypothermia
    • THAM
    • Dihydroergotamine
  • Controversial measures
    • Barbiturate coma if other methods of lowering ICP have failed
    • Decompressive craniectomy