Medical Management of ICP

What is removed in surgical management?

Cranium and Dura

Craniotomy

The removed bone flap is typically replaced after the procedure is completed.

Craniectomy

The removed bone flap is usually not replaced immediately. It may be replaced later in a separate procedure called cranioplasty if necessary → normally more emergent

What are the holes called that they drill in the skull called?

Burr holes

What is the purpose of surgical removal of the cranium and dura?

Create a space for the swelling brain → relieve pressure

Emergency management of ICP - PRIORITY

AIRWAY management

What must be monitored in ICP?

VIGILANT monitoring of NEURO status → subtle change can indicate further comp → EARLY SIGN!!!

Standard imaging to see cause of ICP

CT scan

Why do we test the patients serum osmolality

Monitor effect of Mannitol → quantify the degree of systemic dehydration

What can osmotic diuretics (mannitol) cause?

DEHYDRATION

What will the serum osmolality show in severe dehydration?

RISING

When is mannitol not given to prevent AKI?

If the serum osmolality reaches 320 mOsm/kg

Goal serum sodium range when administering hypertonic saline solutions (above normal)

145-160

Why is the BUN and creatinine monitored?

Hypertonic saline → increase serum osmolality → risk of Acute RENAL FAILURE → monitor renal status

Goal of Medical Management of ICP

we want to increase the osmolality of the BLOOD (vascular space) in order to change the osmotic gradient and cause H2O to DIFFUSE into the BLOOD instead of the brain tissue.

Result of changing the osmotic gradiant

Diffusion of H2O from low concentration (brain tissue/INTERSTITIAL) to high concentration (blood /VASCULAR)

Osmotic Diuretics

Mannitol (Osmitrol)

Where does Mannitol work to cause diuresis?

Kidney → Proximal tubule and Loop of Henle

What is the high concentration sodium chloride used in ICP?

3% normal saliene

What is the benefit of High concentration sodium chloride in comparison to Mannitol?

NO dramatic fluid shifts

How should we compensate for the systemic dehydration and hypovolemia that come with mannitol?

IV FLUID → replace losses

Important note when using sedatives (Midazolam and Propofol)

Advocate for PAIN MANAGEMENT!!

• Morphine

• Fetanyl

How to position pt with ICP

30-45 degrees semi fowlers

Neck midline = Jugular drainage

Avoid Hip Flexion = facilitate venous drainage

PaCO2 range for hyperventilation

30-35 mmHg