HWN Suggests

CRACKCast E225 – Head Trauma

HTS (3% Saline): 100cc over 10min, or 3mL/kg (?higher to 5cc/kg) over 30min with repeat doses q6h to max sodium of 160mmol/L (AEs = renal failure, central pontine myelinolysis, rebound ICP elevation).

Mannitol 1g/kg q6h to a maximum serum osmolality of 320mosm/kg (AEs – hypotension, renal failure, or increased bleeding into a traumatic lesion by decompressing the tamponade effect of a hematoma).

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Featured

 ED Approach to elevated ICP: Pressure Cooker

It has been shown that hypertonic saline has greater efficacy in lowering ICP, but there has been no examination of clinical outcomes. Basically, neither agent has been found to be superior, but hypertonic saline causes less dehydration and renal injury and is easier to dose.

 Hypertonic saline for elevated ICP

For now, either hypertonic saline or mannitol is a reasonable choice if you need to treat an elevated intracranial pressure. When we should be treating elevated ICP and whether such treatment results in any patient oriented benefit is still a mystery. We need some large, high quality trials. If you are running one of those trials, please set the primary outcome as a patient oriented outcome such as neurologically intact survival.

 Osmotherapy

Meta-analysis of available studies shows that mannitol is less effective than hypertonic saline, while being associated with higher rates of kidney injury. A Cochrane analysis found that mannitol might have detrimental effects on mortality, when compared to hypertonic saline. Hypertonic bicarbonate ampules (typically 50 ml of 1 mEq/ml bicarbonate): This has the same tonicity as “6% saline” – making it roughly twice as potent as 3% saline. 2-3 ampules of hypertonic bicarbonate (100-150 ml) may be used as emergent therapy for elevated ICP. The advantage of this therapy is that it's generally immediately available... 3% saline: May be given as a bolus of 250 ml.

Articles of Interest

Pediatric Cerebral Herniation

Dr. Suzanne Beno, Co-director of the Trauma Program at the Hospital for Sick Children in Toronto, tells her Best Case Ever of a child who suffers a severe traumatic head injury with signs of raised intracranial pressure and cerebral herniation.

Brain Herniation

Brain herniation is the displacement of part of the brain through an opening or across a separating structure into a region that it does not normally occupy.

Critical Care Management and Monitoring of Intracranial Pressure

The initial dose of IV mannitol-especially in the setting of ICP crisis- should not be under-dosed...

Cushings Reflex and Triad

Cushings triad signals impending danger of brain herniation, and thus, the need for decompression. Consider administering mannitol, hyperventilation, and elevation of the head of bed as temporizing measures. Cushings triad was first described in 1902 by Harvey Williams Cushing, an American neurosurgeon. -

Emergency Neurological Life Support: Intracranial Hypertension and Herniation

Sustained intracranial hypertension and acute brain herniation are “brain codes,” signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death.

Evidence of Raised Intracranial Pressure on ECG – A Resident Clinical Pearl

Cerebral T waves are deep, symmetric, inverted T-waves seen on an ECG in patients with large intracranial bleeds. They are typically widespread.

Head of the Bed Down: Paradoxical Management for Paradoxical Herniation

Treatment for paradoxical herniation involved increasing intracranial pressure using fluid resuscitation and Trendelenburg positioning. In the intensive care unit our patient received an epidural blood patch and hydration with resolution of his symptoms.

Lumbar Punture: Risk Factors for Brain Stem Herniation in Adults Suspected of Having Bacterial Meningitis

Diagnostic lumbar puncture (LP) results in a mild and transient reduction in cerebral spinal fluid (CSF) pressure due to removal of CSF for diagnostic purposes and ongoing low-volume leakage of CSF from the site of arachnoid membrane puncture. In the presence of intracranial space occupying lesions (inflammatory, neoplastic, or hemorrhagic) or other inflammatory conditions that increase CSF pressure, diagnostic LP can create an acute pressure gradient that results in downward displacement of the cerebrum and brainstem.

Revisiting Cerebral Perfusion Pressure: A Framework for Approaching TBI

Patients requiring airway management are particularly vulnerable to hemodynamic disturbances and hypoxia, and these potential sources of secondary injury should be anticipated and mitigated. Early neurosurgery consultation for patients with severe TBI is essential, as these patients may benefit from invasive procedures, such as ICP monitoring, external ventricular drains, or decompressive craniectomy.

Types of Cerebral Herniation and Their Imaging Features

Cerebral herniation, defined as a shift of cerebral tissue from its normal location into an adjacent space, is a life-threatening condition that requires prompt diagnosis. The imaging spectrum can range from subtle changes to clear displacement of brain structures.

Resources

Early detection of brainstem herniation using electroencephalography monitoring – case report

Continuous electroencephalography (cEEG) is an important neuromonitoring tool in brain injured patients. It is commonly used for detection of seizure but can also be used to monitor changes in cerebral blood flow.

StatPearls

Brain herniation, also called brain code, requires early diagnosis and prompt management in order to prevent irreversible pathological cascades that eventually lead to respiratory arrest and subsequent death.