- •ICU Protocols
- •Preface
- •Acknowledgments
- •Contents
- •Contributors
- •1: Airway Management
- •Suggested Reading
- •2: Acute Respiratory Failure
- •Suggested Reading
- •Suggested Reading
- •Website
- •4: Basic Mechanical Ventilation
- •Suggested Reading
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Websites
- •7: Weaning
- •Suggested Reading
- •8: Massive Hemoptysis
- •Suggested Reading
- •9: Pulmonary Thromboembolism
- •Suggested Reading
- •Suggested Reading
- •Websites
- •11: Ventilator-Associated Pneumonia
- •Suggested Readings
- •12: Pleural Diseases
- •Suggested Reading
- •Websites
- •13: Sleep-Disordered Breathing
- •Suggested Reading
- •Websites
- •14: Oxygen Therapy
- •Suggested Reading
- •15: Pulse Oximetry and Capnography
- •Conclusion
- •Suggested Reading
- •Websites
- •16: Hemodynamic Monitoring
- •Suggested Reading
- •Websites
- •17: Echocardiography
- •Suggested Readings
- •Websites
- •Suggested Reading
- •Websites
- •19: Cardiorespiratory Arrest
- •Suggested Reading
- •Websites
- •20: Cardiogenic Shock
- •Suggested Reading
- •21: Acute Heart Failure
- •Suggested Reading
- •22: Cardiac Arrhythmias
- •Suggested Reading
- •Website
- •23: Acute Coronary Syndromes
- •Suggested Reading
- •Website
- •Suggested Reading
- •25: Aortic Dissection
- •Suggested Reading
- •26: Cerebrovascular Accident
- •Suggested Reading
- •Websites
- •27: Subarachnoid Hemorrhage
- •Suggested Reading
- •Websites
- •28: Status Epilepticus
- •Suggested Reading
- •29: Acute Flaccid Paralysis
- •Suggested Readings
- •30: Coma
- •Suggested Reading
- •Suggested Reading
- •Websites
- •32: Acute Febrile Encephalopathy
- •Suggested Reading
- •33: Sedation and Analgesia
- •Suggested Reading
- •Websites
- •34: Brain Death
- •Suggested Reading
- •Websites
- •35: Upper Gastrointestinal Bleeding
- •Suggested Reading
- •36: Lower Gastrointestinal Bleeding
- •Suggested Reading
- •37: Acute Diarrhea
- •Suggested Reading
- •38: Acute Abdominal Distension
- •Suggested Reading
- •39: Intra-abdominal Hypertension
- •Suggested Reading
- •Website
- •40: Acute Pancreatitis
- •Suggested Reading
- •Website
- •41: Acute Liver Failure
- •Suggested Reading
- •Suggested Reading
- •Websites
- •43: Nutrition Support
- •Suggested Reading
- •44: Acute Renal Failure
- •Suggested Reading
- •Websites
- •45: Renal Replacement Therapy
- •Suggested Reading
- •Website
- •46: Managing a Patient on Dialysis
- •Suggested Reading
- •Websites
- •47: Drug Dosing
- •Suggested Reading
- •Websites
- •48: General Measures of Infection Control
- •Suggested Reading
- •Websites
- •49: Antibiotic Stewardship
- •Suggested Reading
- •Website
- •50: Septic Shock
- •Suggested Reading
- •51: Severe Tropical Infections
- •Suggested Reading
- •Websites
- •52: New-Onset Fever
- •Suggested Reading
- •Websites
- •53: Fungal Infections
- •Suggested Reading
- •Suggested Reading
- •Website
- •55: Hyponatremia
- •Suggested Reading
- •56: Hypernatremia
- •Suggested Reading
- •57: Hypokalemia and Hyperkalemia
- •57.1 Hyperkalemia
- •Suggested Reading
- •Website
- •58: Arterial Blood Gases
- •Suggested Reading
- •Websites
- •59: Diabetic Emergencies
- •59.1 Hyperglycemic Emergencies
- •59.2 Hypoglycemia
- •Suggested Reading
- •60: Glycemic Control in the ICU
- •Suggested Reading
- •61: Transfusion Practices and Complications
- •Suggested Reading
- •Websites
- •Suggested Reading
- •Website
- •63: Onco-emergencies
- •63.1 Hypercalcemia
- •63.2 ECG Changes in Hypercalcemia
- •63.3 Superior Vena Cava Syndrome
- •63.4 Malignant Spinal Cord Compression
- •Suggested Reading
- •64: General Management of Trauma
- •Suggested Reading
- •65: Severe Head and Spinal Cord Injury
- •Suggested Reading
- •Websites
- •66: Torso Trauma
- •Suggested Reading
- •Websites
- •67: Burn Management
- •Suggested Reading
- •68: General Poisoning Management
- •Suggested Reading
- •69: Syndromic Approach to Poisoning
- •Suggested Reading
- •Websites
- •70: Drug Abuse
- •Suggested Reading
- •71: Snakebite
- •Suggested Reading
- •72: Heat Stroke and Hypothermia
- •72.1 Heat Stroke
- •72.2 Hypothermia
- •Suggested Reading
- •73: Jaundice in Pregnancy
- •Suggested Reading
- •Suggested Reading
- •75: Severe Preeclampsia
- •Suggested Reading
- •76: General Issues in Perioperative Care
- •Suggested Reading
- •Web Site
- •77.1 Cardiac Surgery
- •77.2 Thoracic Surgery
- •77.3 Neurosurgery
- •Suggested Reading
- •78: Initial Assessment and Resuscitation
- •Suggested Reading
- •79: Comprehensive ICU Care
- •Suggested Reading
- •Website
- •80: Quality Control
- •Suggested Reading
- •Websites
- •81: Ethical Principles in End-of-Life Care
- •Suggested Reading
- •82: ICU Organization and Training
- •Suggested Reading
- •Website
- •83: Transportation of Critically Ill Patients
- •83.1 Intrahospital Transport
- •83.2 Interhospital Transport
- •Suggested Reading
- •84: Scoring Systems
- •Suggested Reading
- •Websites
- •85: Mechanical Ventilation
- •Suggested Reading
- •86: Acute Severe Asthma
- •Suggested Reading
- •87: Status Epilepticus
- •Suggested Reading
- •88: Severe Sepsis and Septic Shock
- •Suggested Reading
- •89: Acute Intracranial Hypertension
- •Suggested Reading
- •90: Multiorgan Failure
- •90.1 Concurrent Management of Hepatic Dysfunction
- •Suggested Readings
- •91: Central Line Placement
- •Suggested Reading
- •92: Arterial Catheterization
- •Suggested Reading
- •93: Pulmonary Artery Catheterization
- •Suggested Reading
- •Website
- •Suggested Reading
- •95: Temporary Pacemaker Insertion
- •Suggested Reading
- •96: Percutaneous Tracheostomy
- •Suggested Reading
- •97: Thoracentesis
- •Suggested Reading
- •98: Chest Tube Placement
- •Suggested Reading
- •99: Pericardiocentesis
- •Suggested Reading
- •100: Lumbar Puncture
- •Suggested Reading
- •Website
- •101: Intra-aortic Balloon Pump
- •Suggested Reading
- •Appendices
- •Appendix A
- •Appendix B
- •Common ICU Formulae
- •Appendix C
- •Appendix D: Syllabus for ICU Training
- •Index
Acute Intracranial Hypertension |
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Sunit Singhi |
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A 2-year-old unconscious child was brought to the emergency department following fall from the first floor of a building. Initical Glasgow coma score was 6. Both pupils were reactive, blood pressure was 95 mmHg systolic, and heart rate was 120/min. Head CT on admission revealed multiple contusions with cerebral edema. Within 30 min of admission, blood pressure shot up to 130 mmHg, heart rate dropped to 70/min, and the right pupil got dilated.
Acute intracranial hypertension is a medical emergency requiring prompt diagnosis and management. Appropriate and timely management strategies result in better patient’s outcome in an otherwise severely debilitating or fatal disease process.
Step 1: Initiate resuscitation
•Airway (A): Secure airway, do rapid sequence intubation, and maintain/induce sedation with midazolam and/or diazepam.
•Breathing (B): Perform hyperventilation using Ambu bag while waiting for intubation, and maintain PaCO2 of 30–35 mmHg.
•Circulation (C): Assess for euvolemia, give normal saline bolus if central venous pressure is less than 8–10 or systolic blood pressure is less than 5th percentile prior to instituting osmotic therapy.
Step 2: Understand intracranial hypertension
A.Monro–Kellie doctrine
The pathophysiology and management of AIH is based on the Monro–Kellie doctrine. Intracranial pressure (ICP) is the sum total of pressure exerted by the
S. Singhi, M.D., F.C.C.M. (*)
Department of Pediatrics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
e-mail: sunit.singhi@gmail.com
R. Chawla and S. Todi (eds.), ICU Protocols: A stepwise approach, |
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DOI 10.1007/978-81-322-0535-7_89, © Springer India 2012 |
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S. Singhi |
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brain tissue (»80%), blood volume (»10%), and cerebrospinal fluid (»10%) in the noncompliant cranial vault.
B.Normal value
ICP is not a constant value but is variable with various activities such as coughing, sneezing, and age. Single measurement is not a true representation of ICP; it needs to be measured over the period (24–72 h). Usually normal limits are taken as 5–15 mmHg.
C.Acute intracranial hypertension
AIH is a clinical condition defined as the persistent elevation of ICP of more than 20 mmHg for more than 5 min in a patient who is not being stimulated and as a threshold to define intracranial hypertension requiring treatment. Sustained ICP values of more than 40 mmHg indicate severe, life-threatening intracranial hypertension.
•An algorithmic approach to management of ICP (Fig. 89.1) helps put things into perspective so that all aspects of care are attended to.
•Maximize oxygenation and ventilation.
•In an ICP-based therapy, the primary goal is reduction of ICP to less than 20 mmHg.
•In a cerebral perfusion pressure (CPP)-based therapy, systolic blood pressure and mean arterial pressure (MAP) should be maintained to keep CPP more than 60 mmHg.
•CPP = MAP–ICP; MAP = one-third systolic pressure plus two-thirds diastolic pressure.
•Avoid factors that aggravate or precipitate elevated ICP.
•Decrease cerebral metabolic rate.
Step 3: Start general measures
•Keep temperature below 38°C (around-the-clock oral acetaminophen 15 mg/kg 6 hourly).
•Glucose control—keep blood glucose between 80 and 140 mg/dL.
•Avoidance of jugular venous outflow obstruction (head in midline and elevated to 30°).
•Normoxia (PaO2 80–120 mmHg and SpO2 >90%) and normocarbia (PaCO2 35–40 mmHg).
•Preservation of adequate sedation–analgesia.
•Seizure prophylaxis (Phenytoin 20 mg/kg loading, then 5–8 mg/kg/d), for patients at high risk.
•Nutrition—enteral (preferred) to be started within 72 h.
Step 4: Start first-tier ICP-specific treatments
•Ventilate to normocarbia (PCO2 35 mmHg).
•Sedation and pharmacologic paralysis.
•Hyperventilate to PaCO2 of 30–35 mmHg (moderate and transient only, do not prolong, >6 h, and prophylactic hyperventilation).
•Increase MAP.
89 Acute Intracranial Hypertension |
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Neurological examination
Signs and symptoms suggestive of raised ICP or GCS <8
Care of airway, breathing, circulation |
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If resectable |
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Endotracheal intubation |
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mass/hydrocephalous/bleed |
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CT scan/MR imaging |
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Insertion of ICP catheter and ICP |
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Surgical resection/ |
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ventriculostomy/CSF |
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monitoring |
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diversion/evacuation |
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Normocarbia |
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Head midline elevated |
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Minimum stimulation |
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PaCO2≈35 mmHg |
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Normovolemia |
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Prevent or treat fever |
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20–30° |
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Adequate sedation and |
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Normoxia |
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& seizures |
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analgesia |
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PaO2>60 mmHg |
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SpO2>92% |
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ICP>20 mmHg |
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Heavy sedation |
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Osmotherapy: |
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Mild hyperventilation |
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± NM Blockade |
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Mannitol/HTS |
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PaCO2 30–35 mmHg |
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ICP >20 mmHg |
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Refractory intracranial hypertension |
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Barbiturate therapy |
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Moderate hypothermia |
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Hyperventilation |
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Decompressive craniectomy |
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(32-33 C) |
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PaCO2 <30mmHg |
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Fig. 89.1 An approach to the management of intracranial hypertension. ICP Intracranial pressure, GCS Glasgow coma score, HTS hypertonic saline
•Mannitol (0.25–2 g/kg IV bolus every 4–6 h; serum osmolality not >320 mOsmol/kg).
•Saline infusion (3%) (loading 10 mL/kg; 0.1–1 mL/kg/h infusion; serum osmolality not >360 mOsmol/kg).
•Consider ventriculostomy—drain 3–5 mL cerebrospinal fluid.
Step 5: Consider second-tier therapy if ICP is persistently high
•Barbiturates coma (thiopental loading 1–5 mg/kg IV; if complete response [ICP <20 mmHg], return to first-tier agents or repeat bolus doses as necessary; if incomplete response [ICP >20 mmHg but reduction <25%], start IV 1–5 mg/ kg/h infusion or until burst suppression EEG pattern at 1–2 bursts/min).
712 |
S. Singhi |
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•Moderate hypothermia (32–34°C with surface or endovascular cooling method for 24–72 h, followed by passive rewarming over 12–24 h).
Step 6: Consider third-tier therapy
•Decompressive craniectomy or temporal lobectomy (if medical AIH management has failed but the patient does not have overt herniation syndrome yet).
•Hyperventilation for acutely symptomatic patients may be lifesaving.
•Two osmotic agents are currently in use: mannitol and hypertonic saline (3%).
•Induced hypothermia is effective in reducing ICP by suppressing all cerebral metabolic activities.
Suggested Reading
1.Meyer MJ, Megyesi J, Meythaler J, Murie-Fernandez M, Aubut JA, Foley N, Salter K, Bayley M, Marshall S, Teasell R. Acute management of acquired brain injury part I: an evidence-based review of non-pharmacological interventions. Brain Inj. 2010;24(5):694–705.
There is a paucity of information regarding nonpharmacological acute management of patients with ABI. This review found strong levels of evidence for only four interventions (decompressive craniectomy, cerebrospinal fluid drainage, hypothermia, and hyperbaric oxygen).
2.Singhi SC, Tiwari L. Management of intracranial hypertension. Indian J Pediatr. 2009;76(5): 519–29.
A review article on the management of acute intracranial hypertension.
3.Latorre JG, Greer DM. Management of acute intracranial hypertension. Neurologist. 2009;15: 193–207.
The clinical manifestation and principles of management of acute intracranial hypertension are discussed and reviewed.