What is the immediate management for a patient with suspected increased intracranial pressure in the ICU, possibly following a traumatic brain injury?

Management of Drowning in the ICU

Immediate airway control through endotracheal intubation with mechanical ventilation is the absolute priority, followed by strict maintenance of systolic blood pressure >110 mmHg using vasopressors without delay. 1

Initial Resuscitation and Airway Management

Establish definitive airway control immediately through tracheal intubation and mechanical ventilation, with continuous end-tidal CO2 monitoring to confirm correct tube placement and maintain PaCO2 within normal range. 2, 1 This is critical because:

• Hypocapnia induces cerebral vasoconstriction and increases risk of brain ischemia 2
• End-tidal CO2 monitoring must begin from the pre-hospital period and continue throughout ICU care 2
• Airway control decreases mortality in critically ill patients 2

Hemodynamic Stabilization

Maintain systolic blood pressure >110 mmHg from first contact, as even a single episode of hypotension (SBP <90 mmHg) markedly worsens neurological prognosis. 1

• Use vasopressors (phenylephrine or norepinephrine) immediately for hypotension rather than waiting for fluid resuscitation 1
• Avoid sedative agents that cause hypotension, particularly bolus doses of midazolam, opioids, or barbiturates 2
• Use continuous infusions instead of boluses to prevent hemodynamic instability 2, 1

Neurological Assessment and Monitoring

Obtain non-contrast CT of the brain immediately without delay to assess for cerebral edema, hypoxic-ischemic injury, or other intracranial pathology. 1

Implement intracranial pressure monitoring if the patient cannot be neurologically assessed and has signs of high ICP on brain CT scan, abnormal neurological examination, or requires extracranial surgical procedures. 2, 1 Specific indications include:

• Compression of basal cisterns (>70% risk of ICP >30 mmHg) 2
• Brain midline shift >5 mm 2
• Disappearance of cerebral ventricles 2
• Traumatic subarachnoid hemorrhage 2

Do not monitor ICP if initial CT scan is normal with no evidence of clinical severity or transcranial Doppler abnormalities, as the incidence of raised ICP is only 0-8% in this scenario. 2

Management of Intracranial Hypertension

First-Line Medical Management

Elevate head of bed to 30 degrees, maintain normothermia using targeted temperature control, and provide adequate sedation with propofol by continuous infusion. 1, 3

• Propofol administered by infusion or slow bolus in combination with hypocapnia decreases ICP independently of blood pressure changes 1, 4
• Target serum sodium 145-155 mmol/L 5
• Maintain platelet count >100,000/mm³ 1

Hyperosmolar Therapy

For documented intracranial hypertension, use either 7.5% hypertonic saline 250 mL bolus over 15-20 minutes OR 20% mannitol 0.25-0.5 g/kg IV over 20 minutes. 5

Choose hypertonic saline when hypovolemia or hypotension is present; choose mannitol when hypernatremia is already present or improved cerebral oxygenation is the priority. 5

• Both agents are equally effective at equiosmotic doses (~250 mOsm) 5
• Hypertonic saline offers longer duration of effect and shorter ICU stays 5
• Mannitol is the only ICP-lowering therapy associated with improved cerebral oxygenation 5
• Monitor serum osmolality (keep <320 mOsm/L) and sodium (avoid >155-160 mmol/L) 5
• Never use prophylactically without documented intracranial hypertension 5

Hyperventilation

Limit hyperventilation to emergency management of life-threatening raised ICP only, as it causes cerebral vasoconstriction and ischemia. 2, 6

Surgical Interventions

External Ventricular Drainage

Perform external ventricular drainage to treat persisting intracranial hypertension despite sedation and correction of secondary brain insults. 2

• Subtraction of small CSF volume can markedly reduce ICP 2
• Can be inserted using neuronavigation 2

Decompressive Craniectomy

Consider decompressive craniectomy in multidisciplinary discussion for refractory intracranial hypertension after failure of medical management. 2, 1

The evidence shows conflicting outcomes:

• Reduces mortality (26.9% vs 48.9% with barbiturates) but increases poor neurological outcomes (8.5% vs 2.1%) 2
• Unilateral temporal craniectomy (>100 cm²) shows better outcomes than bifrontal craniectomy 2
• Should be performed within first 72 hours if indicated 2
• Age >60-70 years is generally an exclusion criterion 2

Refractory Intracranial Hypertension

For ICP refractory to maximum medical and surgical treatment, administer high-dose barbiturates before considering decompressive craniectomy as a last resort. 6

Critical Pitfalls to Avoid

• Never delay transfer to specialized neurocritical care center for "stabilization" in facility without neurosurgery 1
• Never use sedation boluses instead of continuous infusions 1
• Never allow hypotension during sedation initiation or maintenance 2, 1
• Never prophylactically administer hyperosmolar therapy without documented ICP elevation 5
• Never use aggressive hyperventilation except for life-threatening herniation 2, 6

Supportive Care

• Maintain normothermia as hyperthermia increases complications and death 1
• Implement seizure prophylaxis strategies 1
• Maintain biological homeostasis including osmolality, glycemia, and adrenal function 1
• Consider early palliative care consultation (within 24-72 hours) for severely injured patients 1
• Use PEEP 5-15 cm H₂O as increasing PEEP is associated with decreased ICP and improved cerebral perfusion pressure 1