Template:Increased ICP treatment - Revision history

Danbot: Convert mannitol, fosphenytoin, levetiracetam, and pentobarbital dosing to MedicationDose templates for SMW integration

2026-03-20T22:33:37Z

Convert mannitol, fosphenytoin, levetiracetam, and pentobarbital dosing to MedicationDose templates for SMW integration

← Older revision		Revision as of 22:33, 20 March 2026
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	#[[Mannitol]]<ref>Muizelaar JP, Lutz HA, Becker DP: Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients. J Neurosurg. 1984, 61: 700-706.</ref>		#[[Mannitol]]<ref>Muizelaar JP, Lutz HA, Becker DP: Effect of mannitol on ICP and CBF and correlation with pressure autoregulation in severely head-injured patients. J Neurosurg. 1984, 61: 700-706.</ref>
	#*If SBP > 90 mmHg		#*If SBP > 90 mmHg
	#*Bolus 20% at 0.25-1 gm/kg ~~as rapid infusion~~ over 15-20 min		#*Bolus 20% at {{MedicationDose\|drug=Mannitol\|dose=0.25-1 g/kg IV over 15-20 min\|route=IV\|context=Osmotherapy for elevated ICP\|indication={{PAGENAME}}\|population=Adult\|notes=If SBP >90; target Osm 300-320}}
	#*Target Osm 300-320 mOsm/kg		#*Target Osm 300-320 mOsm/kg
	#*Reduces ICP within 30min, duration of action of 6-8hr		#*Reduces ICP within 30min, duration of action of 6-8hr
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	**Consider prophylaxis in patients with any risk factors as above		**Consider prophylaxis in patients with any risk factors as above
	**[[Phenytoin]] or [[fosphenytoin]] first line agent by BTF guidelines<ref>Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.</ref>		**[[Phenytoin]] or [[fosphenytoin]] first line agent by BTF guidelines<ref>Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.</ref>
	***~~Load~~ 20 PE/kg IV, then 100 PE IV q8hrs ~~for~~ 7 days		***{{MedicationDose\|drug=Fosphenytoin\|dose=20 PE/kg IV load, then 100 PE IV q8hrs x 7 days\|route=IV\|context=Seizure prophylaxis in elevated ICP\|indication={{PAGENAME}}\|population=Adult}}
	***Measure serum levels to titrate to therapeutic levels		***Measure serum levels to titrate to therapeutic levels
	**[[Levetiracetam]] may be used as alternative<ref>Szaflarski JP et al. Prospective, randomized, single blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010;12:165-172.</ref>		**[[Levetiracetam]] may be used as alternative<ref>Szaflarski JP et al. Prospective, randomized, single blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010;12:165-172.</ref>
	***20 mg/kg load IV, ~~followed by~~ 1000 mg IV q12h ~~for~~ 7 days		***{{MedicationDose\|drug=Levetiracetam\|dose=20 mg/kg IV load, then 1000 mg IV q12h x 7 days\|route=IV\|context=Seizure prophylaxis in elevated ICP (alternative)\|indication={{PAGENAME}}\|population=Adult}}
	***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin		***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
	***In many EDs, levetiracetam is current first line therapy		***In many EDs, levetiracetam is current first line therapy
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	*Only for hemodynamically stable patients		*Only for hemodynamically stable patients
	*Induce with the following:		*Induce with the following:
	**[[Pentobarbital]] 10 mg/kg over 30 min		**{{MedicationDose\|drug=Pentobarbital\|dose=10 mg/kg IV over 30 min, then 5 mg/kg/hr x3 hrs, then 1 mg/kg/hr\|route=IV\|context=Barbiturate coma for refractory ICP\|indication={{PAGENAME}}\|population=Adult}}
	**Then 5 mg/kg/hr for 3 hrs		**Then 5 mg/kg/hr for 3 hrs
	**Followed by 1 mg/kg/hr		**Followed by 1 mg/kg/hr

Kfarzam: /* Seizure Control */

2022-08-29T04:24:15Z

Seizure Control

← Older revision		Revision as of 04:24, 29 August 2022
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	***20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days		***20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days
	***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin		***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin
			***In many EDs, levetiracetam is current first line therapy

	====Intubation Pretreatment====		====Intubation Pretreatment====

ClaireLewis at 02:19, 3 October 2019

2019-10-03T02:19:35Z

Lisayee25: /* Intubation Pretreatment */

2017-07-08T15:41:01Z

Intubation Pretreatment

← Older revision		Revision as of 15:41, 8 July 2017
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	''Goal cerebral perfusion pressure (CPP) ~70mmHg''		''Goal cerebral perfusion pressure (CPP) ~70mmHg''
	*If need for [[RSI]], consider pretreatment with [[lidocaine]] and/or [[fentanyl]]		*If need for [[RSI]], consider pretreatment with [[lidocaine]] and/or [[fentanyl]]
			**May contribute to peri-intubation hypotension
	*Also ensure adequate sedation (prevent gag reflex)		*Also ensure adequate sedation (prevent gag reflex)
	*[[Etomidate]] may cause adrenal insufficiency especially in head injured patients, so consider [[hydrocortisone]] if refractory hypotension post-intubation<ref>Schulz-Stübner S: Sedation in traumatic brain injury: avoid etomidate. Crit Care Med. 2005, 33 (11): 2723.</ref>		*[[Etomidate]] may cause adrenal insufficiency especially in head injured patients, so consider [[hydrocortisone]] if refractory hypotension post-intubation<ref>Schulz-Stübner S: Sedation in traumatic brain injury: avoid etomidate. Crit Care Med. 2005, 33 (11): 2723.</ref>

Kxl328 at 08:13, 5 March 2017

2017-03-05T08:13:26Z

← Older revision		Revision as of 08:13, 5 March 2017
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	**Maintain euvolemia, initially resuscitate with Normal Saline		**Maintain euvolemia, initially resuscitate with Normal Saline
	**Then consider hypertonic saline and/or mannitol		**Then consider hypertonic saline and/or mannitol
	**Do not use free water, low osmolal, dextrose solutions, and colloids		**Do not use free water, low osmolal, dextrose-alone solutions, and colloids
	**Do not use Ringer's lactate as it is slightly hypotonic		**Do not use Ringer's lactate as it is slightly hypotonic
			**Prefer NS over D5-NS if possible, but D5-NS may be necessary to avoid hypoglycemia, especially in younger pediatric patients
	**Correction of severe hypernatremia > 160 mmol/L (hypothalamic-pituitary injury, [[diabetes insipidus]]) should be gradual to not worsen cerebral edema		**Correction of severe hypernatremia > 160 mmol/L (hypothalamic-pituitary injury, [[diabetes insipidus]]) should be gradual to not worsen cerebral edema

ClaireLewis: /* Osmotherapies */

2016-10-05T06:55:08Z

Osmotherapies

← Older revision		Revision as of 06:55, 5 October 2016
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	#**Consider hypertonic saline for further boluses		#**Consider hypertonic saline for further boluses
	#**Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol		#**Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol
	#[[Hypertonic ~~Saline~~]] may be more effective than mannitol, current standard of care<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU: Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011, 39 (3): 554-559.</ref>		#[[Hypertonic saline]] may be more effective than mannitol, current standard of care<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU: Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011, 39 (3): 554-559.</ref>
	#*Obtain baseline serum osmolarity and sodium		#*Obtain baseline serum osmolarity and sodium
	#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>		#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>

ClaireLewis: /* Osmotherapies */

2016-10-05T06:54:53Z

Osmotherapies

← Older revision		Revision as of 06:54, 5 October 2016
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	#**Consider hypertonic saline for further boluses		#**Consider hypertonic saline for further boluses
	#**Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol		#**Hypertonic saline has higher osmotic gradient and is less permeable across BBB than mannitol
	#Hypertonic Saline may be more effective than mannitol, current standard of care<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU: Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011, 39 (3): 554-559.</ref>		#[[Hypertonic Saline]] may be more effective than mannitol, current standard of care<ref>Kamel H, Navi BB, Nakagawa K, Hemphill JC, Ko NU: Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011, 39 (3): 554-559.</ref>
	#*Obtain baseline serum osmolarity and sodium		#*Obtain baseline serum osmolarity and sodium
	#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>		#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>

ClaireLewis: /* Osmotherapies */

2016-10-05T06:07:32Z

Osmotherapies

← Older revision		Revision as of 06:07, 5 October 2016
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	#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>		#*Most studies used 250 mL bolus of 7.5% saline with dextran<ref>Holmes, J. Therapeutic uses of Hypertonic Saline in the Critically Ill Emergency Department Patient. EB Medicine 2013</ref>
	#*Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line		#*Initial 250 cc bolus of 3% will reduce ICP and can be delivered through a peripheral line
	#*Target sodium 145-155 mg/dL		#*Target sodium 145-155 mmol/dL

	====Prevent Cerebral Vasoconstriction====		====Prevent Cerebral Vasoconstriction====

Neil.m.young at 13:23, 30 August 2016

2016-08-30T13:23:16Z

← Older revision		Revision as of 13:23, 30 August 2016
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	**Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI<ref>Friess SH et al. Differing Effects when Using Phenylephrine and Norepinephrine To Augment Cerebral Blood Flow after Traumatic Brain Injury in the Immature Brain. J Neurotrauma. 2015 Feb 15; 32(4): 237–243.</ref>		**Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI<ref>Friess SH et al. Differing Effects when Using Phenylephrine and Norepinephrine To Augment Cerebral Blood Flow after Traumatic Brain Injury in the Immature Brain. J Neurotrauma. 2015 Feb 15; 32(4): 237–243.</ref>
	*IV fluids<ref>Haddad SH and Arabi YM. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201220:12.</ref>		*IV fluids<ref>Haddad SH and Arabi YM. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201220:12.</ref>
	**Maintain ~~normovolemic~~, initially resuscitate with Normal Saline		**Maintain euvolemia, initially resuscitate with Normal Saline
	**Then consider hypertonic saline and/or mannitol		**Then consider hypertonic saline and/or mannitol
	**Do not use free water, low osmolal, dextrose solutions, and colloids		**Do not use free water, low osmolal, dextrose solutions, and colloids

Kxl328 at 12:00, 30 August 2016

2016-08-30T12:00:33Z

← Older revision		Revision as of 12:00, 30 August 2016
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	***Measure serum levels to titrate to therapeutic levels		***Measure serum levels to titrate to therapeutic levels
	**[[Levetiracetam]] may be used as alternative<ref>Szaflarski JP et al. Prospective, randomized, single blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010;12:165-172.</ref>		**[[Levetiracetam]] may be used as alternative<ref>Szaflarski JP et al. Prospective, randomized, single blinded comparative trial of intravenous levetiracetam versus phenytoin for seizure prophylaxis. Neurocrit Care 2010;12:165-172.</ref>
	***20 mg/kg load, followed by 1000 mg q12h for 7 days		***20 mg/kg load IV, followed by 1000 mg IV q12h for 7 days
	***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin		***Levetiracetam may have less frequent and severe adverse drug side effects events as compared to phenytoin

← Older revision		Revision as of 02:19, 3 October 2019
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	**May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)		**May be beneficial when patient is tachycardic (reflex bradycardia), but avoid phenylephrine if patient is already bradycardic (Cushing's reflex)
	**Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI<ref>Friess SH et al. Differing Effects when Using Phenylephrine and Norepinephrine To Augment Cerebral Blood Flow after Traumatic Brain Injury in the Immature Brain. J Neurotrauma. 2015 Feb 15; 32(4): 237–243.</ref>		**Phenylephrine may be associated with less cell injury as compared to norepinephrine in TBI<ref>Friess SH et al. Differing Effects when Using Phenylephrine and Norepinephrine To Augment Cerebral Blood Flow after Traumatic Brain Injury in the Immature Brain. J Neurotrauma. 2015 Feb 15; 32(4): 237–243.</ref>
	*IV fluids<ref>Haddad SH and Arabi YM. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201220:12.</ref>		*[[IVF\|IV fluids]]<ref>Haddad SH and Arabi YM. Critical care management of severe traumatic brain injury in adults. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine201220:12.</ref>
	**Maintain euvolemia, initially resuscitate with Normal Saline		**Maintain euvolemia, initially resuscitate with Normal Saline
	**Then consider hypertonic saline and/or mannitol		**Then consider hypertonic saline and/or mannitol
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	*Hyperventilation does not improve mortality, used only as temporizing measure		*Hyperventilation does not improve mortality, used only as temporizing measure
	*Should only be used if reduction in ICP necessary without any other means or ICP elevation refractory to all other treatments:		*Should only be used if reduction in ICP necessary without any other means or ICP elevation refractory to all other treatments:
	**Sedation		**[[Sedation]]
	**Paralytics		**Paralytics
	**CSF drainage		**CSF drainage
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	*Consider propofol for post-intubation sedation		*Consider propofol for post-intubation sedation
	*Seizure prophylaxis reduces seizures but does not improve long-term outcomes<ref>Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.</ref>		*Seizure prophylaxis reduces seizures but does not improve long-term outcomes<ref>Khan AA, Banerjee A. The role of prophylactic anticonvulsants in moderate to severe head injury. Int J Emerg Med. 2010 Jul 22;3(3):187-91.</ref>
	**AEDs prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review<ref>Thompson K, Pohlmann-Eden B, Campbell LA. Pharmacological treatments for preventing epilepsy following traumatic head injury (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009900.</ref>		**[[AEDs]] prevent early seizures (which occur between 24 hrs - 7 days), with NNT = 10 by Cochrane Review<ref>Thompson K, Pohlmann-Eden B, Campbell LA. Pharmacological treatments for preventing epilepsy following traumatic head injury (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD009900.</ref>
	**Risk factors for post-traumatic seizures:		**Risk factors for post-traumatic seizures:
	***GCS < 10 initially		***GCS < 10 initially
	***Cortical contusion		***Cortical contusion
	***Depressed skull fx		***Depressed [[skull fracture]]
	***[[Subdural hematoma]], [[epidural hematoma]]		***[[Subdural hematoma]], [[epidural hematoma]]
	***[[Subarachnoid hemorrhage]] or ICH		***[[Subarachnoid hemorrhage]] or [[ICH]]
	***Penetrating head injury		***Penetrating head injury
	***Seizure within 24 hours of injury (immediate seizure)		***Seizure within 24 hours of injury (immediate seizure)
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	====Decrease metabolic rate====		====Decrease metabolic rate====
	*Provide adequate sedation and analgesia		*Provide adequate sedation and analgesia
	*Avoid HYPERthermia and treat fever aggressively		*Avoid [[hyperthermia\|HYPERthermia]] and treat fever aggressively
	**However, hypothermia is not a necessary goal		**However, hypothermia is not a necessary goal
	**Moderate hypothermia 32°C to 34°C controversial, large RCT showed no effect<ref>Marion DW, Penrod LE, Kelsey SF, et al: Treatment of traumatic brain injury with moderate hypothermia. New Engl J Med. 1997, 336: 540-546.</ref>		**Moderate [[hypothermia]] 32°C to 34°C controversial, large RCT showed no effect<ref>Marion DW, Penrod LE, Kelsey SF, et al: Treatment of traumatic brain injury with moderate hypothermia. New Engl J Med. 1997, 336: 540-546.</ref>
	====Other Critical Care Measures====		====Other Critical Care Measures====
	*DVT prophylaxis with SCDs, no anticoagulation		*DVT prophylaxis with SCDs, no anticoagulation
	*Stress ulcer prophylaxis with H2-blocker/PPI and sucralfate to avoid Cushing's ulcers		*Stress ulcer prophylaxis with [[H2 blocker]]/[[PPI]] and sucralfate to avoid Cushing's ulcers
	*Good glycemic control, but tight maintenance not supported<ref>Marion DW: Optimum serum glucose levels for patients with severe traumatic brain injury. F 1000 Med Rep. 2009, 1: 42.</ref>		*Good glycemic control, but tight maintenance not supported<ref>Marion DW: Optimum serum glucose levels for patients with severe traumatic brain injury. F 1000 Med Rep. 2009, 1: 42.</ref>
	*Steroids, methylprednisolone contraindicated in severe TBI (risk of death increased in CRASH 2004 trial)<ref>Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloë V, Muñoz-Sánchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P, CRASH trial collaborators: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004, 364: 1321-1328.</ref>		*Steroids, methylprednisolone contraindicated in severe TBI (risk of death increased in CRASH 2004 trial)<ref>Roberts I, Yates D, Sandercock P, Farrell B, Wasserberg J, Lomas G, Cottingham R, Svoboda P, Brayley N, Mazairac G, Laloë V, Muñoz-Sánchez A, Arango M, Hartzenberg B, Khamis H, Yutthakasemsunt S, Komolafe E, Olldashi F, Yadav Y, Murillo-Cabezas F, Shakur H, Edwards P, CRASH trial collaborators: Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet. 2004, 364: 1321-1328.</ref>
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	**Increased risk of pneumonia and ICU length of stay		**Increased risk of pneumonia and ICU length of stay
	**However, may be used for refractory ICP elevation		**However, may be used for refractory ICP elevation
	=====~~Barbituate~~ Coma<ref>Kassell NF, Hitchon PW, Gerk MK, Sokoll MD, Hill TR: Alterations in cerebral blood flow, oxygen metabolism, and electrical activity produced by high dose sodium thiopental. Neurosurgery. 1980, 7: 598-603.</ref>=====		=====[[Barbiturate]] Coma<ref>Kassell NF, Hitchon PW, Gerk MK, Sokoll MD, Hill TR: Alterations in cerebral blood flow, oxygen metabolism, and electrical activity produced by high dose sodium thiopental. Neurosurgery. 1980, 7: 598-603.</ref>=====
	*For ICP refractory to maximal medical and surgical therapy		*For ICP refractory to maximal medical and surgical therapy
	*Only for hemodynamically stable patients		*Only for hemodynamically stable patients