Stepladder Management of Increased ICP (ENLS Protocol)

First question to ask in ICP management should be “Does this patient need urgent decompressive hemicraniectomy?”  If ICP crises is progressing rapidly, a neurosurgeon should be consulted urgently to discuss the risks and benefits of surgery.  ICP can be lowered by craniectomy alone (15% decrease) or by craniectomy and dural opening (70% decrease).  Surgical decompression has been shown to improve brain tissue oxgenation, survival in malignant MCA infarction, but does not improve outcomes in TBI.

ENLS ALGORITHM:

Capture

The Neurocritical Society published guidelines on the management of intracranial hypertension and herniation in 2012.  A summary of the four tiers in the stepwise treatment of ICP crises is listed below.

ENLS ICP Treatment Tiers

Tier Zero:

  • HOB > 30 degrees
  • ensure adequate sedation
  • correct hyponatremia, hyperthermia, and vasogenic edema
  • keep CPP > 60-70 mm Hg
  • **normocarbia (PaCO2 35-45)
  • **good oxygenation (PaO2 >100)

Tier One:

  • secure airway
  • mannitol 0.5-1 gm/kg IV bolus
  • start 3% saline 10-20 cc/hr
  • CSF drainage

Tier Two:

  • hypertonic saline bolus (3%-23.4%)
  • consider propofol bolus and infusion
  • consider decompressive craniotomy

Tier Three:

  • pentobarbital bolus and infusion titrated for ICP goal
  • induce hypothermia
  • hyperventilation if used with cerebral oxygen monitor
  • raise MAP to improve CPP

 

NOTES:

  1. achieve normothermia by:
    • acetaminophen 325-650 PO or PR q6h
    • ibuprofen 500mg PO q6h
    • surface cooling – ice packs, cool blankets, surface devices (Arctic Sun)
    • intravascular cooling – catheter inserted into IVC that cools blood, effective and quick but increases risk of venous thrombosis and infection
  2. hyperventilation – effective but lasts only 10-20 hours, CO2 levels <25 can increase risk of brain ischemia, sustained hyperventilation x 5 days has been shown to slow recovery of severe TBI at 3 and 6 months
  3. Mannitol – target osmolality to 300-320, dose is 025 to 1.5 g/Kg bolus IV, watch out for hypotension, hypovolemia and renal tubular damage
  4. barbiturates – pentobarbital most commonly used (that is, if barbiturates are used at all), load with 5-20mg/Kg bolus then 1-4mg/Kg/hr infusion; watch out for hypotension; will lose neurologic exam so requires accurate monitoring to guide therapy – EEG, ICP, hemodynamics

 

ORDER SHEET:

See link below for MS Word / PDF document of sample order sheet for management of ICP crisis.

ICP Crisis Order Sheet

ICP Crisis Order Sheet (Sy, MD)

References

Miller, Chad M, and Michel T Torbey. Neurocritical Care Monitoring. Print.

Stevens, Robert D., Michael Shoykhet, and Rhonda Cadena. “Emergency Neurological Life Support: Intracranial Hypertension And Herniation”. Neurocritical Care 23.S2 (2015): 76-82. Web.

Advertisements

Tagged: , , , ,

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: