What initial medications should be started on admission for a patient with acute post‑traumatic hydrocephalus?

Initial Medication Management for Post-Traumatic Hydrocephalus on Admission

The primary initial intervention for acute post-traumatic hydrocephalus is surgical drainage via external ventricular drain (EVD), not medical management, as this is the definitive treatment for both intracranial hypertension and hydrocephalus itself. 1

Immediate Surgical Intervention

• External ventricular drainage should be performed urgently to treat acute hydrocephalus and control intracranial pressure, particularly when intracranial hypertension persists despite sedation and correction of secondary brain insults 1
• Drainage of cerebrospinal fluid is the therapeutic option of choice for controlling intracranial pressure in hydrocephalus, with even small volumes of CSF removal producing marked ICP reduction 1
• In pediatric cases with aqueductal obstruction from blood clot, urgent EVD placement is indicated for intracranial hypertension at presentation 2

Osmotic Therapy for Acute ICP Management

If signs of brain herniation or threatened intracranial hypertension are present before EVD placement, administer mannitol 20% or hypertonic saline at a dose of 250 mOsm as a 15-20 minute infusion after controlling secondary brain insults (hypotension, hypoxia). 1

Osmotic Agent Selection:

• Mannitol and hypertonic saline have comparable efficacy at equiosmotic doses (approximately 250 mOsm) for treating intracranial hypertension 1
• Mannitol induces osmotic diuresis requiring volume compensation, while hypertonic saline causes hypernatremia and hyperchloremia requiring electrolyte monitoring 1
• Osmotherapy provides maximum effect after 10-15 minutes with duration of 2-4 hours 1
• Mannitol is the only ICP-lowering therapy associated with improved cerebral oxygenation compared to external ventricular drainage and hyperventilation 1

Sedation and Analgesia

Adequate sedation and analgesia are essential first-line measures for all patients with suspected intracranial hypertension, applied immediately before more aggressive interventions. 3

For Intubated Patients:

• High-dose fentanyl (3-5 µg/kg), alfentanil (10-20 µg/kg), or remifentanil target-controlled infusion (Cpt ≥3 ng/ml) for analgesia 1
• Use continuous infusions rather than bolus doses to minimize hemodynamic fluctuations 4
• Ketamine 1-2 mg/kg may be useful in hemodynamically unstable patients 1
• Maintain systolic blood pressure >110 mmHg at all times, as hypotension significantly worsens neurological outcomes 4

Propranolol for Severe TBI

Propranolol should be initiated within 24-48 hours of injury at 1 mg IV every 6 hours for patients with severe traumatic brain injury requiring ICU admission, as this reduces mortality by approximately 60%. 5

Inclusion Criteria:

• Severe TBI or moderate TBI requiring ICU admission 5
• Admission within 24-48 hours of injury 5
• Systolic blood pressure maintained >110 mmHg 5
• No symptomatic bradycardia or hypotension 5
• ICU setting with continuous cardiovascular monitoring available 5

Contraindications:

• Symptomatic bradycardia 5
• Refractory hypotension despite vasopressor support 5
• Inability to maintain SBP >110 mmHg 5

Critical Medications to AVOID

Do NOT administer 4% albumin solution to severe TBI patients, as it increases mortality (41.8% vs 22.2% with normal saline, RR 1.88). 1

Avoid prolonged hypocapnia (PaCO2 <30 mmHg) as a treatment for intracranial hypertension, as it worsens neurological outcomes by exacerbating secondary ischemic lesions. 1

Supportive Medical Management

Blood Pressure Management:

• Maintain systolic blood pressure >110 mmHg to prevent secondary brain injury 1, 4
• Have vasopressors (ephedrine, metaraminol, phenylephrine, norepinephrine) immediately available 1, 4
• Consider judicious use of vasopressor infusions (e.g., metaraminol) to offset hypotensive effects of sedatives 1

Ventilation Control:

• Monitor end-tidal CO2 to maintain PaCO2 within normal range (avoid both hypercapnia >6 kPa and hypocapnia <4.0 kPa) 1
• Hypocapnia induces cerebral vasoconstriction and is a risk factor for brain ischemia 1

Glucose Management:

• Target blood glucose 6-10 mmol/L 1

Common Pitfalls to Avoid

• Do not delay EVD placement in favor of medical management alone—surgical drainage is the definitive treatment 1
• Never use opioid bolus dosing—use continuous infusions to prevent hemodynamic instability 4
• Do not assume "normal" blood pressure is adequate—maintain SBP >110 mmHg specifically 4
• Avoid prophylactic osmotherapy in patients without evidence of intracranial hypertension, as it provides no outcome benefit 1
• Be aware of catastrophic brainstem hemorrhage risk with lumbar drain placement in decompressive craniectomy patients 6