Critical Care Medicine-Neurologic Disorders>>>>>Neurotrauma
Question 10#

A 47-year-old male is found to have refractory elevation in ICP following a TBI in the setting of a motor vehicle accident. His neuro examination is poor, with GCS of 5. A head CT was obtained which demonstrated signs of bilateral frontal and temporal contusions.

Which of the following methods will help reduce ICP?

a. Loading with topiramate
b. Cooling to 34°C
c. Supination with flat head of the bed
d. Maintaining a serum sodium strictly less than 145 mg/dL
e. Adjusting the ventilator to target PaCO2 of 35 to 40

Correct Answer is B

Comment:

Correct Answer: B

Elevated ICP is a common complication of acute severe TBI. There is a stepwise approach in the management of intracranial hypertension which starts with head of bed elevation, and hyperosmolar therapy (mannitol and hypertonic saline). Securing airways should always take priority and starting the patient on sedation like propofol and versed could help controlling ICP. ICP monitors should always be considered to guide treatment and provide CSF drainage if needed. If ICP remains refractory, other measures including barbiturates, to provide more sedation and reduce brain metabolism, and neuromuscular paralysis, to control shivering, should be also considered. Therapeutic hypothermia is one of the effective treatments to reduce ICP if less invasive approaches were ineffective. The effect of therapeutic hypothermia on clinical outcomes in TBI with refractory ICPs remains debated. While hyperventilation (PaCO2 of 25-30) is a good way to acutely lower ICP, it should not be used for more than 30 minutes due to the risk of rebound elevation in ICP when the PaCO2 is normalized. Elevated serum sodium is likely to benefit patients with elevated ICP, and therefore there is no reason to strictly maintain sodium below 145. Controlling seizures is helpful in keeping ICP low, but topiramate is rarely the agent used to control active seizure presentation. For intracranial hypertension refractory to initial medical management, CSF drainage, hypothermia, and barbiturate coma, decompressive craniectomy should be considered.

References:

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  3. Polderman KH, Tjong Tjin Joe R, Peerdeman SM, et al. Effects of therapeutic hypothermia on intracranial pressure and outcome in patients with severe head injury. Intensive Care Med. 2002;28(11):1563- 1573.
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