What is the initial management of raised intracranial tension?

Initial Management of Raised Intracranial Pressure

The initial management of raised intracranial pressure should follow a stepwise approach beginning with airway management, head elevation, osmotherapy with mannitol (0.25-2 g/kg IV over 30-60 minutes), and careful monitoring of vital signs and neurological status. 1, 2

Immediate Interventions

• Establish and secure airway, provide adequate oxygenation, and ensure proper ventilation to prevent hypoxemia and hypercarbia which can exacerbate cerebral edema 1, 2
• Elevate head of bed to 20-30° to promote venous drainage and help reduce intracranial pressure 1, 3
• Maintain neutral neck position to avoid jugular venous compression 3
• Restrict free water and avoid hypo-osmolar fluids that may worsen cerebral edema 1
• Correct factors that could exacerbate swelling such as hypoxemia, hypercarbia, and hyperthermia 1
• Avoid antihypertensive agents that cause cerebral vasodilation 1

Pharmacological Management

• Administer mannitol as first-line osmotic therapy:
  • Adults: 0.25-2 g/kg IV as a 15-25% solution over 30-60 minutes 4
  • Pediatric patients: 1-2 g/kg or 30-60 g/m² body surface area over 30-60 minutes 4
  • Small or debilitated patients: 500 mg/kg 4
  • Maximum effect occurs within 10-15 minutes with duration of 2-4 hours 5
• Consider hypertonic saline as an alternative osmotic agent, although less extensively evaluated in all patient populations 6
• Provide adequate sedation to attain a quiet, motionless state to reduce metabolic demands 7

Monitoring and Assessment

• Monitor intracranial pressure if indicated (abnormal CT findings, GCS ≤8, inability to perform adequate neurological assessment) 8, 5
• Maintain cerebral perfusion pressure (CPP) between 60-70 mmHg 8, 5
• Avoid CPP <60 mmHg (associated with worse outcomes) and >90 mmHg (may worsen vasogenic edema) 8
• Monitor electrolytes closely as mannitol can cause significant fluid and electrolyte imbalances 4
• Assess for signs of neurological deterioration including declining consciousness, focal neurological deficits, and pupillary abnormalities 1, 2

Advanced Measures for Refractory Increased ICP

• Consider short-term hyperventilation (PCO₂ 26-30 mmHg) only as a temporizing measure for impending herniation 7, 3
• If ICP remains elevated despite above measures, consider:
  • Neurosurgical consultation for possible decompressive surgery 2
  • High-dose barbiturate therapy in selected cases 7, 2
  • Neuromuscular paralysis in intubated patients 2

Contraindications and Precautions

• Avoid mannitol in patients with:
  • Well-established anuria due to severe renal disease 4
  • Severe pulmonary congestion or frank pulmonary edema 4
  • Active intracranial bleeding (except during craniotomy) 4
  • Severe dehydration 4
  • Progressive heart failure or pulmonary congestion after starting mannitol 4
  • Known hypersensitivity to mannitol 4
• Steroids are not recommended for management of raised ICP in most acute settings as their effect remains unclear and may adversely affect outcomes 1

Important Considerations

• Recognize that ICP >20-40 mmHg is associated with 3.95 times higher risk of mortality and poor neurological outcome 5
• When ICP exceeds 40 mmHg, mortality risk increases 6.9 times 5
• The effect of mannitol is temporary, and repeated doses may be necessary 1, 6
• Avoid concomitant administration of nephrotoxic drugs with mannitol due to increased risk of renal failure 4
• Carefully evaluate circulatory and renal reserve before administering mannitol, especially at higher doses and rapid infusion rates 4