Can I administer 3% sodium chloride (NaCl) 100 cc push to a patient with active brain herniation and potential increased intracranial pressure (ICP), considering their past medical history, including any history of renal disease or heart failure?

Emergency Hypertonic Saline Administration for Active Brain Herniation

Yes, you can and should administer 3% NaCl 100 cc as a rapid push in a patient with active brain herniation—this is a life-saving emergency intervention supported by current guidelines. 1, 2

Immediate Administration Protocol

For active herniation with signs such as mydriasis, anisocoria, or acute neurological deterioration, osmotherapy is the treatment of choice and should be given immediately, even in the prehospital setting. 1

Recommended Dosing for 3% Hypertonic Saline

• Initial bolus: 5 mL/kg IV over 15 minutes (approximately 350 mL for a 70 kg patient), which can be given as a rapid push over 2-5 minutes in emergency situations 2, 3
• Alternative emergency dosing: 100-150 mL rapid IV push over 2-5 minutes for immediate ICP reduction 3, 4
• Follow with continuous infusion at 1 mL/kg per hour, targeting serum sodium 150-155 mEq/L 2

Route of Administration

Peripheral IV access is safe and effective for 3% NaCl administration—you do not need to delay for central line placement. 4 A prospective study of 299 administrations demonstrated no soft tissue injury or necrosis with peripheral administration, and ICP reduction was equivalent between peripheral and central routes (median ICP reduction -24 mm Hg peripheral vs -13 mm Hg central). 4

Physiological Targets During Resuscitation

Blood Pressure Management

• Maintain systolic BP >110 mmHg and MAP >90 mmHg 1
• Cerebral perfusion pressure (CPP) should be maintained at 60-70 mmHg throughout treatment 2
• Have vasopressors immediately available (phenylephrine, norepinephrine, ephedrine, or metaraminol) 1

Ventilation Parameters

• Target PaCO2 4.5-5.0 kPa (34-38 mmHg) 1
• For impending uncal herniation specifically, a brief period of PaCO2 4.0-4.5 kPa may be used 1
• Prolonged severe hypocapnia is NOT recommended as it worsens neurological outcomes through cerebral ischemia 1

Comparative Efficacy: 3% NaCl vs Mannitol

At equiosmotic doses (approximately 250 mOsm), mannitol and hypertonic saline have comparable efficacy for treating intracranial hypertension. 1 However, key differences favor hypertonic saline in certain scenarios:

When to Choose 3% Hypertonic Saline Over Mannitol

• Presence of hypotension or hypovolemia—hypertonic saline increases blood pressure and has minimal diuretic effect 2, 5
• Hemodynamic instability—mannitol causes osmotic diuresis requiring volume replacement 1
• Renal impairment concerns—mannitol can cause renal failure, especially when serum osmolality exceeds 320 mOsm/L 5

When to Choose Mannitol

• Hypernatremia is already present 5
• Improved cerebral blood flow rheology is desired 5

Safety Profile of Rapid 3% NaCl Administration

Rapid administration of 3% NaCl over 2-5 minutes is well-tolerated with minimal adverse events. 3 In a prospective study of 79 administrations:

• SBP decrease ≥20 mmHg occurred in only 13% of patients 3
• Hypotension (SBP <90 mmHg) occurred in 16% 3
• Bradycardia occurred in only 3% 3
• Injection site pain was reported in one patient without tissue damage 3

Critical Monitoring Parameters

Immediate Monitoring (Within 1 Hour)

• Neurological status: GCS, pupillary response, motor function 2
• Hemodynamics: Blood pressure, heart rate, MAP 3
• ICP if monitoring in place: Expected reduction of 13-24 mm Hg 4

Ongoing Monitoring (Every 4-6 Hours)

• Serum sodium, chloride, and osmolality 2
• Target serum sodium: 150-155 mEq/L on maintenance infusion 2
• Renal function and fluid balance 1

Important Clinical Caveats

Maximum Safe Sodium Levels

Do not allow serum sodium to exceed 155 mEq/L on maintenance hypertonic saline infusion. 2 While peak sodium levels up to 170.7 mEq/L have been reported in pediatric studies without adverse effects, conservative targets are recommended. 1

Risk of Osmotic Demyelination

Osmotic demyelination syndrome has NOT been documented in multiple studies using hypertonic saline for elevated ICP, including autopsy and MRI evidence in patients with high sodium levels. 1 A series of 68 patients receiving 23.4% hypertonic saline boluses showed no evidence of osmotic demyelination on post-treatment MRI. 1

Contraindications and Precautions

• Avoid hypoosmolar maintenance fluids—use isotonic or hypertonic fluids only 5
• Monitor for hyperchloremic metabolic acidosis with prolonged use 1
• Avoid 4% albumin solution in severe TBI patients—associated with increased mortality (RR 1.62) 1

Definitive Management Considerations

Osmotherapy is a temporizing measure—arrange for urgent neurosurgical evaluation and imaging to identify surgically correctable lesions. 1, 5 Decompressive craniectomy may be necessary if medical management fails, particularly in large hemispheric strokes with herniation. 5

Adjunctive Measures

• Head elevation to 30 degrees with midline head positioning 1
• Adequate sedation and analgesia to prevent ICP spikes 6
• External ventricular drainage if hydrocephalus present 1
• Avoid hyperthermia and maintain normothermia 7