Increased Intracranial Pressure
PED-14
Diagnosis
ICP > 20 or too high for situation (discuss with neurosurgeon)
If GCS < 9, respiratory distress, hemodynamic instability:
- Secure airway
- Provide sedation prior to transport
Keep PaCO2 35-40 mmHg and PaO2 > 80 mmHg
Maintain cerebral perfusion pressure (discuss goal CPP with team)
- CPP = MAP - ICP
Discuss target ICP with neurosurgery, will often want ICP < 20
Use vasopressors (phenylephrine or NOREPInephrine) as needed to maintain BP and CPP Minimum MAP to optimize CPP Age (yrs) MAP 0-4 >45 5-8 >55 >8 >60
Consider head of bed at 30°
Hypertonic saline (3% saline via central venous catheter) 1-5 mL/kg over 20 min, then 0.1-2 mL/kg/hour; goal ICP < 20 mmHg
- Monitor serum sodium
- Keep osmolarity < 360 mOsm/L
If hypertonic saline not available, can give mannitol 0.25-1 g/kg, over 20 minutes to decrease ICP
Consider furosemide 1-2 mg/kg (starting MAX 20 mg) to decrease ICP
Consider seizure prophylaxis: Keppra (levetiracetam) 10-30 mg/kg IV (MAX 2500 mg)
Consult with neurosurgery colleagues about draining CSF directly or via ventriculostomy
Refractory elevated ICP treatment, consider:
- Barbiturate coma
- Paralysis with non-depolarizing agent
AVOID:
- Compression of neck vessels
- Hyperthermia
- Hyperglycemia & dextrose containing solutions (maintain glucose level < 200 mg/dL)
Crisis Management (If Severe)
Notify surgeon, call for help and code cart
Call for Transesophageal Echocardiography
Start chest compressions
Give epinephrine 10 MICROgrams/kg IV/IO
If cardiac arrest, go to CARDIAC ARREST
Consider ECMO
Drugs
| 3% Saline | 1-5 mL/kg over 20 min |
|---|---|
| 3% Saline | Then infusion 0.1-2 mL/kg/hour |
| Mannitol | 0.25-1 g/kg over 20 min |
| Furosemide | 1-2 mg/kg, starting MAX 20 mg |
| Keppra (levetiracetam) | 10-30 mg/kg IV, MAX 2500 mg |