Management of raised ICP

Abirami

Staff Nurse, Maa Kauvery, Trichy, Tamil Nadu

Definition

Any increase of ICP more than normal value for age is defined as raised ICP. Sustained increase of ICP ≥20 mm HG of hg for ≥5 min warrants treatment. For practical purposes. If symptoms and signs of raised ICP are present one should consider that ICP is 20 mm hg and manage accordingly

Goal

To reduce the ICP and simultaneously to treat the underlying cause

Causes of Raised ICP

  • Trauma
  • Infection
  • Brain Tumor/Swelling in the brain
  • Hydrocephalus
  • Cerebral edema
  • Stroke or Vascular malformation
  • Severe Hypertension
  • Hydrocephalus
  • Aneurysm
  • Infections such as encephalitis or meningitis

Signs and Symptoms of Raised ICP

  • Head Ache
  • Vomiting
  • Seizures
  • Altered Sensorium
  • Visual & Gait disturbances
  • Focal motor weakness
  • Papillary edema
  • Hypertension with Bradycardia
  • Bradycardia
  • Impaired eye movement

Management

First Tier Measures

Head Position: Head in midline and head elevation to 30*

Minimal Stimulation: Reduce painful interventions/excessive stimulation. Lignocaine IV (1mg / Kg/ Dose slow IV) or nebulization should be used prior to ET Suction

Adequate sedation and analgesia and maintain comfort pain score 12 to 17

Maintain normal temperature: Avoid hyperthermia. Can consider IV paracetamol 15mg / kg ,6th hourly

Glycemic Control: Maintain normoglycemia (120 -150 mg/dl). Avoid hypoglycemia (< 60 mg/dl) and hyperglycemia (> 150 mg/dl)

Maintain normoxemia (SPO2 > 92 % and PaO2 – 90 – 100 mmhg). Avoid hyper/hypocarbia (Maintain PCO2 – 35-40 mmhg)

Secure arterial line and do invasive BP monitoring. Maintain MAP > 50th centile for age /Sex/ height

Hemoglobin target: Maintain Hb above 7g /dl

Osmo therapy: Hypertonic saline (Usual dose is 5 – 10 ml /kg loading followed by 0.1 – 1 ml/kg/hr as infusion to maintain target serum Na of 145 – 155 mEq /L) or 20 % mannitol (Dose ranges between 0.5 to 1.5 g /kg/dose over 30 min)

Seizure prophylaxis: Phenytoin or levetiracetam can be used

Infection: Anti-microbial therapy

Second Tier Measures

Barbiturate Coma: Thiopentone Sodium – Loading dose (2–7 mg/kg) over one hour followed by continuous infusion(1-5mg/kg/hr) or phenobarbitone infusion

Hyperventilation: To reduce PaCO2 transiently to 30–35 mmhg

Third Tier Measures

Decompressive craniotomy for refractory raised ICP in children with non-traumatic coma due to focal pathology and midline shift. Tumor resection.

Kauvery Hospital