What is the management for vomiting caused by increased Intracranial Pressure (ICP)?

Management of Vomiting Caused by Increased Intracranial Pressure (ICP)

For vomiting caused by increased intracranial pressure, the management includes medical therapy with repeated lumbar punctures as initial treatment, followed by neurosurgical intervention if needed, along with supportive measures to control symptoms. 1

Initial Assessment and Management

• Vomiting is a common symptom of increased ICP, often accompanied by headache, altered mental status, and gait abnormalities 1
• Immediate neuroimaging (preferably contrast-enhanced MRI) should be performed to evaluate for hydrocephalus, mass lesions, or other causes of increased ICP 1
• Maintain head of bed elevation at 20-30° to help reduce ICP through improved venous drainage 2
• Ensure adequate airway protection, as vomiting increases aspiration risk in patients with altered consciousness 1

Medical Management of Increased ICP

First-Line Interventions:

• Repeated lumbar punctures to reduce pressure - remove sufficient CSF to reduce pressure to 50% of opening pressure or 200 mm H₂O, whichever is greater 1
• Continue daily lumbar punctures for approximately 4 days until pressure stabilizes to <250 mm H₂O 1
• Administer antiemetics promptly to control vomiting and reduce risk of aspiration 1
• Maintain adequate cerebral perfusion pressure (CPP) ≥60 mmHg while managing ICP 2

Pharmacological Management:

• Osmotic diuretics: Mannitol (0.5-1 g/kg IV bolus) is effective for acute management of increased ICP 1
• Mannitol dose may be repeated once or twice as needed, provided serum osmolality remains <320 mosm/L 1
• Avoid prophylactic use of mannitol; only administer when clinical signs of increased ICP are present 1
• Consider acetazolamide or other diuretics for less acute cases of ICP elevation 3

Surgical Management

• If medical therapy with repeated lumbar punctures fails to stabilize ICP, neurosurgical consultation for shunting procedures is necessary 1
• Early neurosurgical consultation is recommended as most patients with persistently increased ICP will require permanent shunt placement 1
• Ventriculoperitoneal or lumboperitoneal shunting may be required for long-term management 1
• For patients with shunts who develop new vomiting, evaluate for shunt malfunction or infection 1

Monitoring and Follow-up

• Monitor for signs of neurological deterioration: changes in mental status, pupillary abnormalities, or worsening symptoms 1
• Repeat neuroimaging if there is any change in mental status, vomiting, cranial neuropathy, or gait disturbance 1
• Watch for signs of hydrocephalus on imaging: ventriculomegaly and transependymal edema 1
• Monitor opening pressure during lumbar punctures to assess treatment efficacy 1

Special Considerations

• In patients with coagulopathy, correction of coagulation abnormalities may be necessary before lumbar puncture 1
• Hyperventilation should be avoided as a prophylactic measure but may be considered for acute, life-threatening increased ICP not controlled by other measures 1
• In patients with renal impairment, mannitol may cause volume overload requiring dialysis 1
• Corticosteroids may be beneficial in certain cases of increased ICP, particularly when associated with inflammation, though evidence is mixed 1

Pitfalls to Avoid

• Do not delay treatment of increased ICP when clinical signs are present, even if imaging is pending 4
• Avoid indiscriminate use of sedatives which may mask neurological deterioration 1
• Do not rely solely on clinical signs for diagnosis as papilledema and other classic signs may be late findings 1
• Avoid prophylactic hyperventilation as it may cause cerebral vasoconstriction and potentially worsen cerebral edema 1