What is the management approach for brainstem herniation leading to cardiac arrest?

Management of Brainstem Herniation Leading to Cardiac Arrest

The management of brainstem herniation leading to cardiac arrest requires immediate high-quality CPR with chest compressions at a rate of 100-120 compressions per minute and a depth of at least 2 inches (5 cm), while simultaneously addressing the underlying cause of herniation through a stepwise approach to reduce intracranial pressure. 1, 2

Initial Resuscitation Approach

• Begin high-quality CPR immediately with minimal interruptions to maintain cerebral and coronary perfusion 1
• Apply defibrillator/AED as soon as possible to identify and treat shockable rhythms if present 1
• Establish advanced airway (endotracheal tube or supraglottic airway) with confirmation using waveform capnography 1
• After advanced airway placement, provide 8-10 breaths per minute with continuous chest compressions 1
• Rotate compressors every 2 minutes to maintain effective compressions 2

Addressing Brain Herniation

• Elevate the head of bed to 30° if tolerated to reduce cerebral edema 1
• Administer osmotherapy (mannitol or hypertonic saline) immediately for impending cerebral herniation 3
• Consider temporary hyperventilation (PaCO2 30-35 mmHg) only as a rescue therapy for acute herniation signs (dilated pupils, bradycardia, hypertension) 3
• Return to normocarbia (PaCO2 35-40 mmHg) once immediate herniation is controlled to prevent cerebral vasoconstriction 3, 4
• Maintain arterial oxygen saturation between 94-98% to avoid both hypoxia and hyperoxia 3

Hemodynamic Management

• Maintain mean arterial pressure (MAP) > 80 mmHg or systolic blood pressure > 100 mmHg to ensure adequate cerebral perfusion 3
• Administer vasopressors (norepinephrine preferred) if needed to maintain blood pressure targets 3
• Ensure adequate intravascular volume while avoiding excessive fluid administration that could worsen cerebral edema 3
• Maintain hemoglobin > 7 g/dL (higher threshold may be considered in elderly or patients with limited cardiovascular reserve) 3

Neurosurgical Interventions

• Obtain urgent neuroimaging (CT scan) to evaluate the cause and extent of brain herniation 1
• Consider immediate neurosurgical consultation for potential life-saving interventions 3
• For cerebellar infarction or hemorrhage causing herniation, suboccipital decompressive craniectomy should be performed emergently 3
• External ventricular drainage placement should be considered for hydrocephalus, but not as the sole intervention due to risk of upward herniation 3

Post-ROSC Management

• Implement targeted temperature management (32-34°C) for 24 hours in comatose survivors after return of spontaneous circulation 1, 5
• Monitor intracranial pressure if patient remains comatose after resuscitation 3
• Maintain cerebral perfusion pressure > 60 mmHg 3
• Avoid hyperthermia as it worsens neurological outcomes 3
• Treat seizures aggressively with appropriate anticonvulsants 3

Monitoring and Prevention of Secondary Injury

• Monitor for signs of increased intracranial pressure (pupillary changes, Cushing's triad) 1
• Maintain normoglycemia (avoid both hyperglycemia and hypoglycemia) 1
• Correct coagulopathy: maintain platelet count > 50,000/mm³ and PT/aPTT < 1.5 times normal 3
• Consider ICP monitoring after coagulopathy correction in salvageable patients 3
• Avoid early prognostication as it may be unreliable, especially if the patient has been treated with therapeutic hypothermia 1

Special Considerations

• For patients with devastating brain injury, a period of physiological stabilization and observation is recommended to improve decision-making quality 3
• Communication with family should be clear about the goals of care, explaining that admission to ICU is to allow time for accurate prognostication 3
• Consider organ donation as a routine part of end-of-life care planning when appropriate 3
• Avoid hyperventilation except as a temporary measure for acute herniation, as it can worsen cerebral blood flow and neurological outcomes 4
• Implement a comprehensive, structured treatment protocol which may improve survival after cardiac arrest 2

Pitfalls to Avoid

• Do not delay CPR or herniation management while waiting for neuroimaging 1
• Avoid excessive hyperventilation which can decrease cerebral blood flow and worsen outcomes 4
• Do not place an external ventricular drain without addressing mass effect on the brainstem in posterior fossa lesions 3
• Avoid early limitation of care based on perceived poor neurological prognosis 5
• Do not delay neurosurgical intervention in patients with posterior fossa mass effect, as 85% of patients progressing to coma die without intervention 3