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 (pt 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 pts based on autoregulation status.
8. Consider second-tier therapies for refractory elevated ICP
   • Decompressive craniectomy
   • High-dose barbiturate therapy (“pentobarb coma”)
   • Hypothermia to 33°C