From the Guidelines
Brain herniation is a medical emergency that requires immediate treatment with osmotic diuretics, such as mannitol 20% or hypertonic saline solution, to reduce intracranial pressure and prevent further brain damage. The diagnosis of brain herniation is based on clinical signs and symptoms, including altered consciousness, abnormal pupil responses, irregular breathing patterns, and abnormal posturing. The treatment of brain herniation focuses on reducing intracranial pressure through measures like hyperventilation, osmotic diuretics, and sometimes surgical decompression 1.
Key Treatment Strategies
- Osmotic diuretics, such as mannitol 20% or hypertonic saline solution, are recommended to treat threatened intracranial hypertension or signs of brain herniation after controlling secondary brain insults 1.
- The dose of mannitol or hypertonic saline solution should be 250 mOsm, infused over 15-20 minutes 1.
- Hyperventilation may be used as a temporary measure to decrease PCO2 by 5 to 10 mm Hg and produce enough vasoconstriction to temporarily lower ICP 1.
- Surgical decompression may be necessary in some cases to relieve pressure on the brain.
Important Considerations
- Monitoring of fluid, sodium, and chloride balances is necessary when using osmotic diuretics like mannitol or hypertonic saline solution 1.
- Patients with brain herniation typically require intubation and mechanical ventilation to maintain adequate oxygenation and control carbon dioxide levels.
- The prognosis of brain herniation depends on the cause, extent of herniation, and how quickly treatment begins.
Nursing Care
- The head of the bed should be elevated 20° to 30°, and the neck should be in a neutral position to facilitate venous drainage 1.
- Good head and body alignment, pain management, and normothermia are also important aspects of nursing care for patients with brain herniation 1.
From the FDA Drug Label
1 INDICATIONS & USAGE
Mannitol Injection is indicated for the following purposes in adults and pediatric patients. Therapeutic Use Reduction of intracranial pressure and brain mass. Reduction of high intraocular pressure. Diagnostic Use Measurement of glomerular filtration rate.
The diagnosis of brain herniation (cerebral herniation) is not directly addressed in the provided drug label. However, reduction of intracranial pressure is mentioned as a therapeutic use of mannitol, which can be related to the treatment of brain herniation. The treatment for brain herniation may involve reduction of intracranial pressure using mannitol (IV) 2. Key points for treatment:
- Reduction of intracranial pressure
- Use of mannitol (IV) Note that the provided drug label does not explicitly address the diagnosis of brain herniation.
From the Research
Diagnosis of Brain Herniation
- Brain herniation is a life-threatening condition that requires immediate diagnosis and treatment 3, 4, 5
- Diagnosis is based on clinical signs and symptoms, as well as radiographic findings such as computed tomography (CT) scans 4, 6
- Intracranial pressure (ICP) monitoring is commonly used to detect changes in ICP and enable early treatment of intracranial hypertension 3, 6
- However, ICP monitoring may not always accurately reflect the severity of brain herniation, and clinical signs and symptoms should also be taken into account 6
Treatment of Brain Herniation
- The overall goal of treatment is to lower ICP and maintain cerebral perfusion pressure (CPP) between 60 mm Hg and 90 mm Hg 3
- Therapeutic interventions to lower ICP include decompressive surgery, osmotherapy, hyperventilation, barbiturate-induced metabolic suppression, and hypothermia 3, 7
- Osmotherapy is considered the mainstay of medical therapy and should be administered as soon as possible 7
- Surgical intervention, such as decompressive craniotomy, may be necessary in some cases 6, 5
- The selection of therapeutic interventions should be tailored to each patient based on their specific diagnosis and intracranial pathophysiology 3