Elevated Intracranial Pressure (ICP) / Herniation - Diagnosis and Management
Etiologies: Mass (tumor, abscess, hemorrhage), cerebral edema (massive infarction, hyperammonemia, DKA), hydrocephalus (tumor, intraventricular hemorrhage, leptomeningeal disease, meningitis), PRES. If ICP severely elevated then herniation (displacement and compression of brain tissue) ensues. LP in setting of significantly raised ICP may also result in herniation.
Signs of hernation: fixed/dilated/asymmetric pupil (often 1 first) accompanied by nausea, somnolence/confusion, limited upgaze; flexor/extensor posturing; ipsilateral hemiparesis (uncal herniation); Cushing’s triad (bradycardia, HTN, & irregular breathing)
Tests: STAT head CT
• STAT Neurosurg. (p21111) (for ICP monitor/EVD placement/decompressive hemicraniectomy)
• Secure ABCs, elevate HOB to 30-45˚, keep head midline (to secure venous drainage), treat pain/agitation
• Neuro-ICU level monitoring (p20202 can help coordinate)
• Hyperventilate to PaCO2 ~ 30-35 mmHg (if suspect herniation, transiently reduceds ICP), only for short-term management
• IV mannitol therapy 1g/kg q6h (use with caution in pts on HD) and/or 23% saline 15cc q6h. Check BMP, Sosm q6h. No mannitol if osm gap >15, Na >160, or serum osm >340. No 23% saline if Na >160.
• If related to edema from malignancy or bacterial infection, give 10mg IV dexamethasone x 1, then 4mg q6hrs
• Complications during LP: if sx of herniation/opening pressures > 40 cm H2O, consider STAT head CT. Immediately replace stylet into needle, only drain CSF in the manometer, STAT Neurosurgery
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