What is the management approach for a patient with severe head trauma and increased intracranial pressure (ICP) who requires a burr hole procedure?

From the Guidelines

The management of a patient with severe head trauma and increased intracranial pressure (ICP) requiring a burr hole procedure should prioritize immediate transfer to a specialized neurosurgical center for emergent intervention. This approach is supported by evidence suggesting that specialized centers have improved outcomes for patients with severe traumatic brain injury due to the expertise and availability of neurosurgeons 1. The burr hole procedure should be performed by a neurosurgeon to evacuate hematomas and relieve pressure, and prior to surgery, the patient should be stabilized with airway management, including rapid sequence intubation, to prevent further ICP increases.

Some key considerations in the management of these patients include:

• Maintaining systolic blood pressure between 100-160 mmHg to ensure adequate cerebral perfusion while avoiding hypertension that could worsen bleeding
• Administering osmotic therapy with mannitol or hypertonic saline to reduce cerebral edema
• Positioning the patient with head elevation at 30 degrees to promote venous drainage
• Mild hyperventilation can temporarily reduce ICP in critical situations
• Initiating seizure prophylaxis with levetiracetam
• Targeting normothermia for temperature management to avoid increasing cerebral metabolic demands

Following the burr hole procedure, continuous ICP monitoring should be established with a target ICP below 22 mmHg and cerebral perfusion pressure (CPP) maintained between 60-70 mmHg, as part of a comprehensive approach to address the primary pathology and prevent secondary brain injury 1.

From the FDA Drug Label

The dosage, concentration and rate of administration depend on the age, weight and condition of the patient. Reduction of Intracranial Pressure and Brain Mass: Adults: 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes In adults a dose of 0. 25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes; pediatric patients 1 to 2 g/kg body weight or 30 to 60 g/m2 body surface area over a period of 30 to 60 minutes.

The management approach for a patient with severe head trauma and increased intracranial pressure (ICP) who requires a burr hole procedure may involve the administration of mannitol to reduce ICP. The recommended dosage is 0.25 to 2 g/kg body weight as a 15% to 25% solution administered over a period of 30 to 60 minutes 2 2.

• Key considerations:
  • Careful evaluation of the patient's circulatory and renal reserve prior to and during administration of mannitol
  • Monitoring of fluid and electrolyte balance, body weight, and total input and output before and after infusion of mannitol
  • Evidence of reduced cerebral spinal fluid pressure must be observed within 15 minutes after starting infusion.

From the Research

Management Approach for Severe Head Trauma and Increased ICP

The management of severe head trauma with increased intracranial pressure (ICP) involves a multi-faceted approach, including surgical interventions such as burr hole procedures. The key considerations in managing such patients include:

• Monitoring of ICP to guide treatment decisions 3, 4, 5
• Use of ICP-lowering therapies, with more aggressive options reserved for patients showing no response to first-tier interventions or with refractory intracranial hypertension 3
• Surgical options, including decompressive craniectomy and burr hole evacuation, for patients with severe TBI and increased ICP 6, 4

Surgical Options for Increased ICP

Surgical options for managing increased ICP in patients with severe head trauma include:

• Decompressive craniectomy, which involves removing a portion of the skull to allow the brain to expand and reduce ICP 3, 4
• Burr hole evacuation, which involves creating a small hole in the skull to drain blood or fluid and reduce ICP 6
• Craniotomy, which involves creating a larger opening in the skull to evacuate a hematoma or repair damaged blood vessels 6

Considerations for Burr Hole Procedure

The decision to perform a burr hole procedure should be made on an individual basis, taking into account the patient's specific condition and prognosis 3, 6. The procedure may be considered for patients with:

• Acute subdural hematoma (ASDH) or acute epidural hematoma (AEDH) 6
• Increased ICP that is refractory to medical management 3, 4
• Clinical deterioration or signs of brain herniation 6, 5

Additional Considerations

Additional considerations in the management of severe head trauma and increased ICP include:

• The importance of multimodality monitoring to provide more robust prognostic information 3, 4, 5
• The need for a patient-centered approach to decision-making, taking into account the patient's values and preferences 3
• The importance of local multidisciplinary protocols to guide treatment decisions and improve outcomes 4