Management of Management of Intracranial Intracranial
Hypertension in Hypertension in Traumatic Brain InjuryTraumatic Brain Injury
Management of Management of Intracranial Intracranial
Hypertension in Hypertension in Traumatic Brain InjuryTraumatic Brain Injury
Kiran Hebbar, MDKiran Hebbar, MD5/31/055/31/05
Introduction:Head Injury
• Adolescents• Boys>>Girls• Leading cause of
trauma death
• Primary & Secondary Injury
Key Concepts• Monroe-Kellie
Doctrine
• CPP=MAP-ICP
• Cerebral Blood Flow
Monroe-Kellie• Skull is a fixed, rigid structure• Total Volume
– Brain– Blood– CSF
Monroe Kellie
Skull= Brain+ Blood+ CSF
Brain+ Blood+ CSF
Goals• Maintain Cerebral Perfusion Pressure
– >60 mm Hg
• Control Cerebral Blood Flow
CPP= MAP-ICP• CPP- Keep >60
• MAP– Hypertensive therapy
• ICP
• Skull= Brain+ Blood+ CSF
Cerebral Blood Flow• Blood Pressure
• PaCO2
• PaO2
• Skull= Brain+ Blood+ CSF
Cerebral Perfusion
• Skull= Brain+ Blood+ CSF
Carbon Dioxide
Skull= Brain+ Blood+ CSF
Oxygen
Skull= Brain+ Blood+ CSF
Quick Review• Importance of Perfusion
• Controlling Blood flow
• So what can we do?
Management Strategies
• Blood– General
• Head Position– Midline
– 30 degrees
• Temperature
Skull= Brain+ Blood+ CSF
Hyperventilation• Blood continued• Decrease CO2
– Vasoconstriction
• Decrease blood volume
• Skull= Brain+ Blood+ CSF
Sedation• Blood continued• Sedative + Analagesic
• Pentobarbital Coma
– Burst suppression
• Skull= Brain+ Blood+ CSF
Management Strategies
• Blood continued
– Surgical- Evacuate Bleed/Clot
Skull= Brain+ Blood+ CSF
CSF
Balance in production and absorption disturbed!
Skull= Brain+ Blood+ CSF
Management• Cerebrospinal Fluid
– Surgical• External Ventricular
Drain (EVD)
– Medical• Acetazolimide• Lasix
Skull= Brain+ Blood+ CSF
Management Strategies
• Brain
– Surgical- Resection
– Osmotic Agents•Mannitol•3% NaCl
Skull= Brain+ Blood+ CSF
Management Strategies
• Brain continued
• Hemicraniectomy
Management Summary • 1. Head Position• 2. Hyperventilate (intubate)• 3. Osmotic Therapy• 4.Sedation/Paralysis• 5. Temperature• 6. Hypertensive Therapy• 7. Surgical- EVD/pressure monitor
Thank You! Make time to
Decompress!!!!