-key history: +LOC = global cerebral dysfunction (may cause apnea)
—prolonged extraction or intubation at scene (any 2ary injury)
CPP = MAP – ICP
HOB >30 (but <75) – to optimize CPP
Clinical signs of herniation:
-decreased MS (“he’s just tired, he hasn’t slept all night”) – RAS in midbrain
-blown pupil(s) = compression of CN3
-Cushing triad = HTN, reflex bradycardia, irregular respiration
-posturing (“he’s agitated”) – deCORticate (limbs go to core, knees flex), decerebrate
Impending herniation on CT: midline shift, effacement of ventricles
-MRI needed to visualize posterior fossa lesions
Salvage therapies (on clinical herniation):
–hypertonic saline: good for hypotensive or hemodynamically unstable pts
—-iv pushes in crashing pts: 6.5-10 mL/kg
—-continuous infusion: start at 0.1 mL/kg/h, titrate to effect. Draw Posm.
–mannitol: ?localized increased ICP (not supported by lit). 0.5-1g/kg.
–hyperventilation (intubated pts) – do NOT hyperventilate prophylactically (worsens cerebral ischemia)
Prevent secondary injury (starting immediately in the ED), specifically:
^keep head forward-facing (prevent obstruction of venous outflow)
-use nicardipine to treat persistently elevated MAPs. Start at lowest dose and titrate to upper limit of MAP goal range
—-goal MAP range is age-specific. Look it up!
-prevent hypo/hypernatremia (goal 135-145)
-avoid fever and hypothermia
-antiseizure ppx (phenytoin) only for supratentorial lesions (not for cerebellar)
Push for ICP monitoring (placement of EVD/External Ventricular Device) regardless of type of bleed.
—in adults, weight risk/benefit of placement for pts on AC