Outline the techniques you would use to control intra-cranial pressure in a patient with a severe closed head injury.
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).
This question closely resembles Question 12 from the first paper of 2004.
Stereotypical steps in ICP management: