Pharmacological interventions for Elevated ICP

• Initial pharmacological interventions for elevated intracranial pressure (ICP) includes titrated fentanyl (25–50 mcg IV every 5 minutes) for analgesia.
• Propofol can be used for sedation to reduce cerebral metabolic demand but an alternative is dexmedetomidine, however it may cause hypotension/bradycardia.

Barbiturate-Induced Coma Dosing

• Pentobarbital loading dose: 10 mg/kg IV over 30 minutes, followed by 1–4 mg/kg/h infusion.
• Monitor for hypotension, requiring vasopressors during pentobarbital use.

Osmolar Therapy Options for Acute ICP Spikes

• Mannitol: 0.25–1 g/kg IV every 6 hours (max serum osmolality 320 mOsm/kg), preferred in fluid overload.
• 23.4% hypertonic saline: 30 mL IV every 6 hours (max serum sodium 160 mEq/L); use a central line.
• 3% hypertonic saline: 30–50 mL/hr continuous infusion.

Side Effects of Propofol and Dexmedetomidine in ICP Management

• Propofol: Hypotension (dose-dependent).
• Dexmedetomidine: Hypotension, bradycardia, ventilator dyssynchrony (no respiratory drive suppression).

First-Line Treatment for Acute Seizures

• Lorazepam: 0.1 mg/kg IV (max 4 mg).
• Follow with second-line antiepileptics

Second-Line Antiepileptic Options for Status Epilepticus

• Fosphenytoin: 20 mg PE/kg IV (max 1500 mg PE).
• Levetiracetam: 60 mg/kg IV (max 4500 mg).
• Valproic acid: 40 mg/kg IV (max 3000 mg).

Prophylactic Levetiracetam in TBI

• Used to reduce early seizures (first 7 days).
• Dosage: 500 mg twice daily for 7 days, adjust for renal function.
• Avoid phenytoin due to neurocognitive risks.

Contraindications for Prophylactic Anticonvulsant Use

• Intracerebral hemorrhage (ICH).
• Post-cardiac arrest (no proven benefit, worse outcomes).

Blood Pressure Targets Post-Cardiac Arrest and in ICH

• Post-cardiac arrest: MAP >65 mm Hg, SBP >90 mm Hg.
• ICH: Target SBP <140 mm Hg (or <160 mm Hg in chronic hypertension), avoid MAP <65 mm Hg.

Risks of Hyperoxemia Post-Resuscitation

• Hyperoxemia increases oxidative brain injury.
• Safe PaO2 range: 80–120 mm Hg (SpO2 high 90s).

Appropriate Use of Hyperventilation for ICP Management

• Only for life-threatening cerebral herniation or severe ICP unresponsive to osmolar therapy.
• Target PaCO2 35–40 mm Hg otherwise.

Stepwise Medical Interventions for Elevated ICP

• Elevate head 30°, neutral neck position.
• Treat fever (<37°C).
• Minimize ICP triggers (e.g., suctioning).
• Osmolar therapy.
• CSF drainage (if ventriculostomy present).
• Barbiturates/hypothermia for refractory cases.

Indications for Decompressive Craniectomy in TBI

• Refractory ICP >25 mm Hg for ≥1 hour.
• Reduces mortality, but not disability-free survival.

Targeted Temperature for Induced Hypothermia in Refractory ICP

• 32–36°C.
• Avoid rapid rewarming to prevent rebound ICP spikes.

Mnemonic for ICP Management Steps

• "HEAD UP"
• Head elevation
• Euvolemia/Electrolyte balance
• Analgesia/Sedation
• Drain CSF
• Use Osmolar Therapy
• Pentobarbital/Hypothermia

RescueICP Trial Conclusion on Decompressive Craniectomy

• Reduced 6-month mortality by 22% in TBI with refractory ICP.
• No improvement in moderate/severe disability rates.

Contraindications to Dexmedetomidine

• Bradycardia
• Hypotension
• Hypersensitivity

Max Serum Sodium Level During Hypertonic Saline Use

• 160 mEq/L

EEG Guidance for Pentobarbital Dosing

• Titrate to achieve "burst suppression" pattern.

Reasons to Avoid Phenytoin for TBI Prophylaxis (Beyond 7 Days)

• Associated with worse neurocognitive outcomes.
• Levetiracetam is preferred.