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Table 19-1

Stepwise Approach to Treatment of Elevated ICPa

Insert ICP monitor—ventriculostomy versus parenchymal device

General goals: maintain ICP <20 mmHg and CPP ≥60 mmHg. For ICP >20-25 mmHg for >5 min:

  1. Elevate head of the bed; midline head position
  2. Drain CSF via ventriculostomy (if in place)
  3. Osmotherapy—mannitol 25-100 g q4h as needed (maintain serum osmolality <320 mosmol) or hypertonic saline (30 mL, 23.4% NaCl bolus)
  4. Glucocorticoids—dexamethasone 4 mg q6h for vasogenic edema from tumor, abscess (avoid glucocorticoids in head trauma, ischemic and hemorrhagic stroke)
  5. Sedation (e.g., morphine, propofol, or midazolam); add neuromuscular paralysis if necessary (patient will require endotracheal intubation and mechanical ventilation at this point, if not before)
  6. Hyperventilation—to PaCO2 30-35 mmHg (short-term use or skip this step)
  7. Pressor therapy—phenylephrine, dopamine, or norepinephrine to maintain adequate MAP to ensure CPP ≥60 mmHg (maintain euvolemia to minimize deleterious systemic effects of pressors). May adjust target CPP in individual patients based on autoregulation status.
  8. Consider second-tier therapies for refractory elevated ICP
    1. Decompressive craniectomy
    2. High-dose barbiturate therapy (“pentobarb coma”)
    3. Hypothermia to 33°C (91.4°F)

aThroughout ICP treatment algorithm, consider repeat head computed tomography to identify mass lesions amenable to surgical evacuation. May alter order of steps based on directed treatment to specific cause of elevated ICP.

Abbreviations: CPP, cerebral perfusion pressure; ICP, intracranial pressure; MAP, mean arterial pressure; PaCO2, arterial partial pressure of carbon dioxide.