Ensure data accurate
Observe for accurate waveforms in arterial and ICP monitors
EVD zeroed at ear, changes with coughing/positioning
Arterial line zeroed at ear (for accurate CPP measurement; although typically level at heart reasonably accurate
Assess ABC (as increased ICP often causes decline in mental status)
If need to intubate - ensure measures to avoid coughing/bucking (increases ICP)
Lidocaine 1% 1ml/kg 1x IV bolus as premedication
Observe for accurate waveforms in arterial and ICP monitors
EVD zeroed at ear, changes with coughing/positioning
Arterial line zeroed at ear (for accurate CPP measurement; although typically level at heart reasonably accurate
EVD zeroed at ear, changes with coughing/positioning
Arterial line zeroed at ear (for accurate CPP measurement; although typically level at heart reasonably accurate
If need to intubate - ensure measures to avoid coughing/bucking (increases ICP)
Lidocaine 1% 1ml/kg 1x IV bolus as premedication
Lidocaine 1% 1ml/kg 1x IV bolus as premedication
Keep CPP 60-110mmHg
If <110 utilize pressors (norepinephrine [preferred] or neosynephrine)
Levophed: start at 4 mcg/min; maximum 20 mcg/min.
Phenylephrine: start at 0.4 mcg/kg/min; maximum 9 mcg/kg/min.
Keep ICP < 20mmHg (nonsustained temporary elevations <5 minutes ok)
If <110 utilize pressors (norepinephrine [preferred] or neosynephrine)
Levophed: start at 4 mcg/min; maximum 20 mcg/min.
Phenylephrine: start at 0.4 mcg/kg/min; maximum 9 mcg/kg/min.<unk> Head of bed to 30-45 deg to increase CSF outflow and keep head midline
May "sandbag" head of those in c-collar to promote venous drainage(c-collar can restrict venous outflow)
Control agitation/pain
Opioids, benzodiazepines, sedative hypnotics
Favor short acting medications to allow neuro exam checks
Midazolam, fentanyl and propofol are often appropriate.
Maintain normocapnia (pCO2 35-40)
Maintain normothermia
Treat shivering
Bair hugger (warms skin temperature)
APAP 650 q6h PRN for temperature >38.5°F
Maintain euvolemia
Maintain euglycemia
May "sandbag" head of those in c-collar to promote venous drainage(c-collar can restrict venous outflow)
Opioids, benzodiazepines, sedative hypnotics
Favor short acting medications to allow neuro exam checks
Midazolam, fentanyl and propofol are often appropriate.
Favor short acting medications to allow neuro exam checks
Midazolam, fentanyl and propofol are often appropriate.
Treat shivering
Bair hugger (warms skin temperature)
APAP 650 q6h PRN for temperature >38.5°F
Bair hugger (warms skin temperature)
APAP 650 q6h PRN for temperature >38.5°F
Hyperventilate to pCO2 30-35mmHg
Oxygen saturation >95%
This is short term as patient will equilibrate; is only meant as a temporizing measure. Attempt to wean to normocapnia as soon as able. Further do not over-ventilate past 25mmHg as may exacerbate damage via cerebral hypoxia (CO2 is primarily involved in autoregulation of cerebral vasculature).
Hypertonic fluids
Mannitol 20% 1-1.5g/kg rapid IV bolus (no need for central line) as an osmotic diuretic to lower ICP OR
23% Na 30mL over 15 minutes (Needs central line)
Consult Neurosurgery (urgent) for possible evacuation or ventricular drainage
This is especially relevant for mass lesions causing mass effect, hydrocephalus and intracranial bleeds
This is short term as patient will equilibrate; is only meant as a temporizing measure. Attempt to wean to normocapnia as soon as able. Further do not over-ventilate past 25mmHg as may exacerbate damage via cerebral hypoxia (CO2 is primarily involved in autoregulation of cerebral vasculature).
Mannitol 20% 1-1.5g/kg rapid IV bolus (no need for central line) as an osmotic diuretic to lower ICP OR
23% Na 30mL over 15 minutes (Needs central line)
This is especially relevant for mass lesions causing mass effect, hydrocephalus and intracranial bleeds
Hypertonic fluid maintenance
Iatrogenic hypernatremia. Use 3% NaCl to maintain na >145 with q6hr serum Na cks.
3%NS at 1mL/kg/hr appropriate (typically start at 50mL/hr).
May continue to push Na > 145, then >150 then >155 prn to manage ICP
Eventually osmotic<unk> s will equilibrate over days. requiring higher Na values (rationale behind pushing Na slowly upward as needed rather than pushing hypernatremia to maximum).
Iatrogenic hyperosmolar maintenance
Mannitol 20% 0.5g/kg q4hrs with serum Osm checks q6hrs. (Target osm of 300-320 mOsm/L)
Iatrogenic hypernatremia. Use 3% NaCl to maintain na >145 with q6hr serum Na cks.
3%NS at 1mL/kg/hr appropriate (typically start at 50mL/hr).
May continue to push Na > 145, then >150 then >155 prn to manage ICP
Eventually osmotic<unk> s will equilibrate over days. requiring higher Na values (rationale behind pushing Na slowly upward as needed rather than pushing hypernatremia to maximum).
Iatrogenic hyperosmolar maintenance
Mannitol 20% 0.5g/kg q4hrs with serum Osm checks q6hrs. (Target osm of 300-320 mOsm/L)
3%NS at 1mL/kg/hr appropriate (typically start at 50mL/hr).
May continue to push Na > 145, then >150 then >155 prn to manage ICP
Eventually osmotic<unk> s will equilibrate over days. requiring higher Na values (rationale behind pushing Na slowly upward as needed rather than pushing hypernatremia to maximum).
Eventually osmotic<unk> s will equilibrate over days. requiring higher Na values (rationale behind pushing Na slowly upward as needed rather than pushing hypernatremia to maximum).
Mannitol 20% 0.5g/kg q4hrs with serum Osm checks q6hrs. (Target osm of 300-320 mOsm/L)
Pentobarbital coma
loading dose: 5-20mg/kg bolus then 4mg;kg/hr titrated to burst supression on EEG.
Induced hypothermia (32-34°F)
Cooling System (ie. Arctic Sunt, Stryker Medi-Therm)
Must perform surveillance cultures (routine blood culture, UA, CXR) every 48 hours since artificially supressing fever.
Shivering protocol
Vecuronium or pancuronium 
Paralytics
Risk of ICU myopathy/neuropathy with long term use.
loading dose: 5-20mg/kg bolus then 4mg;kg/hr titrated to burst supression on EEG.
Cooling System (ie. Arctic Sunt, Stryker Medi-Therm)
Must perform surveillance cultures (routine blood culture, UA, CXR) every 48 hours since artificially supressing fever.
Shivering protocol
Vecuronium or pancuronium 
Must perform surveillance cultures (routine blood culture, UA, CXR) every 48 hours since artificially supressing fever.
Vecuronium or pancuronium 
Risk of ICU myopathy/neuropathy with long term use.
Elevated intracranial pressure
Intracranial hemorrhage
Ventriculoperitoneal shunt obstruction
Intra-axial
Post-lumbar puncture headache
Hemorrhagic stroke 
Ventriculoperitoneal shunt overdrainage
Traumatic intracerebral hemorrhage