From the Guidelines
An intracranial pressure (ICP) of 15 mmHg in a patient with traumatic brain injury (TBI) is at the upper limit of normal but warrants close monitoring due to the risk of developing intracranial hypertension. The normal ICP range is between 5-15 mmHg, and treatment is typically initiated when ICP exceeds 20-22 mmHg 1. However, in the context of TBI, where secondary brain injury can evolve rapidly, close monitoring is essential.
Key Considerations
- The patient should be monitored with serial neurological examinations and continuous ICP monitoring if available.
- First-tier interventions would include elevating the head of bed to 30 degrees, maintaining adequate sedation, ensuring normothermia, and avoiding hypotension or hypoxia.
- Maintaining cerebral perfusion pressure (CPP) above 60 mmHg is crucial, calculated as mean arterial pressure minus ICP.
Management Strategies
- Hypertonic saline has been shown to reduce ICP in patients with TBI, either alone or in combination with a colloid solution, as demonstrated in several case-control studies and randomised-controlled trials 1.
- The use of hypertonic saline, in concentrations ranging from 1.7% to 30% saline, most often as bolus doses of 250 ml, has been effective in reducing ICP in TBI patients 1.
Outcome Prioritization
The primary concern in managing a patient with TBI and an ICP of 15 mmHg is to prevent secondary brain injury by maintaining optimal cerebral perfusion and avoiding further increases in ICP.
- This involves careful monitoring and prompt intervention if clinical deterioration occurs or ICP trends upward.
- The goal is to minimize morbidity, mortality, and improve quality of life by preventing long-term neurological damage.
From the Research
Significance of 15mmHg ICP on a Patient with TBI
- An intracranial pressure (ICP) of 15mmHg is considered elevated and may be associated with increased risk of secondary brain injury in patients with traumatic brain injury (TBI) 2.
- Elevated ICP is a significant cause of secondary brain injury and ICP monitoring has become an established component of brain monitoring after TBI 2.
- The management of elevated ICP requires an algorithmic approach that utilizes prophylactic measures and acute intervention treatments to mitigate the risk of secondary brain injury 3.
Treatment Options for Elevated ICP
- Hyperosmolar agents such as hypertonic saline and mannitol are commonly used to reduce ICP in patients with TBI 4, 5.
- Hypertonic saline is associated with faster resolution of intracranial hypertension and restoration of optimal cerebral hemodynamics, although these advantages did not translate into long-term benefits in morbidity or mortality 4.
- Mannitol resulted in significant albeit moderate improvement of cerebral perfusion, and had no ostensible effect on oxidative or glucose metabolism and lactate balance 5.
Monitoring and Diagnostic Tools
- Physical examination results and noninvasive assessments of the optic nerve sheath diameter (ONSD) via sonography are positively associated with elevated ICP, and are employed as diagnostic and monitoring tools for elevated ICP in resource-limited settings 3.
- ICP monitoring can also be augmented by measurement of indices describing cerebrovascular pressure reactivity and pressure-volume compensatory reserve 2.