Raised intracranial pressure may occur in a number of different medical or surgical conditions but whenever present rapid intervention is important to reduce the morbidity and mortality associated with it. Therapies differ some what based on etiology, although some generalization do apply. Therapy should be started as soon as raised ICP is suspected. Care should be coordinated with a pediatric neurosurgeon.
1. Immediate Actions
Immediate actions should always include proper evaluation and management of patient’s airway, breathing and circulation. Cerebral perfusion pressure should be adequate to provide blood flow to the brain.
2. Position Of The Patient
Simple first maneuvers should include having child lay supine, with head of bed elevated to 30 degrees and child’s head in a midline position. Use care when positioning the head of a trauma patient with potential cervical spine injury.
3. Ventilation
Maintaining adequate oxygenation and ventilation is of primary importance.Because CO2 is a cerebral vasodilator , maintaining normal PaCO2(40mmHg) helps decrease ICP by decreasing cerebral blood volume. Hyperventilation is indicated only in the setting of impending herniation.
4. Osmotic Therapy
Osmotic therapy consists of either mannitol (0.5-1 g/kg) or 3% saline (3-5 ml/kg). Both agents helps in reducing ICP.
5. Sedation and Seizure Control
Adequate sedation and keeping patient calm helps to reduce ICP and brain injury by reducing oxygen demand of the brain cells. In a similar fashion, control of seizure activity is beneficial both in reducing ICP and in reducing brain’s oxygen requirements. Barbiturates are often used to produce sedation, coma and seizure control.
6. Steroids
Steroids have proven beneficial in reducing vasogenic edema associated with mass lesions such as tumors within the brain. However , there is no proven benefit in administrating steroids to patients with traumatic brain injury.
7. B.P Management
To maintain adequate cerebral perfusion pressure mean arterial pressure should be adequate. Fluid administration may be given as 3% salineto expand blood volume with the benefit of osmotic therapy, or blood may be given if indicated as in history of large amount of blood loss in trauma. Vasoactive agents may be necessary to increase mean arterial pressure enough to produce a sufficient cerebral perfusion pressure.
8. Diuretics
Furosemide especially when administered with mannitol may augment the osmolar benefits. again caution must be taken to avoid hypotension. Acetazolamide, a carbonic anhydrase inhibitor, can reduce CSF production and hence delay worsening of ICP caused by hydrocephalus.
9. Surgical Intervention
Surgical intervention has two benefits:
Immediate actions should always include proper evaluation and management of patient’s airway, breathing and circulation. Cerebral perfusion pressure should be adequate to provide blood flow to the brain.
2. Position Of The Patient
Simple first maneuvers should include having child lay supine, with head of bed elevated to 30 degrees and child’s head in a midline position. Use care when positioning the head of a trauma patient with potential cervical spine injury.
3. Ventilation
Maintaining adequate oxygenation and ventilation is of primary importance.Because CO2 is a cerebral vasodilator , maintaining normal PaCO2(40mmHg) helps decrease ICP by decreasing cerebral blood volume. Hyperventilation is indicated only in the setting of impending herniation.
4. Osmotic Therapy
Osmotic therapy consists of either mannitol (0.5-1 g/kg) or 3% saline (3-5 ml/kg). Both agents helps in reducing ICP.
5. Sedation and Seizure Control
Adequate sedation and keeping patient calm helps to reduce ICP and brain injury by reducing oxygen demand of the brain cells. In a similar fashion, control of seizure activity is beneficial both in reducing ICP and in reducing brain’s oxygen requirements. Barbiturates are often used to produce sedation, coma and seizure control.
6. Steroids
Steroids have proven beneficial in reducing vasogenic edema associated with mass lesions such as tumors within the brain. However , there is no proven benefit in administrating steroids to patients with traumatic brain injury.
7. B.P Management
To maintain adequate cerebral perfusion pressure mean arterial pressure should be adequate. Fluid administration may be given as 3% salineto expand blood volume with the benefit of osmotic therapy, or blood may be given if indicated as in history of large amount of blood loss in trauma. Vasoactive agents may be necessary to increase mean arterial pressure enough to produce a sufficient cerebral perfusion pressure.
8. Diuretics
Furosemide especially when administered with mannitol may augment the osmolar benefits. again caution must be taken to avoid hypotension. Acetazolamide, a carbonic anhydrase inhibitor, can reduce CSF production and hence delay worsening of ICP caused by hydrocephalus.
9. Surgical Intervention
Surgical intervention has two benefits:
- Introduction of appropriate intracranial monitoring devices that can monitor the ICP and response to therapy; these include catheters placed in the ventricular space or brain parenchyma.
- Removal of what is in excess in the intracranial vault, including CSF, blood or tumor mass.
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