There is always a considerable amount of debate generated when it comes to issues of managing raised intracranial pressure secondary to post-traumatic head injury (based on clinical and radiological signs) in the ED.
When the case is clearly one for neurosurgical intervention (like clearing a large extradural or subdural bleed), then there is hardly any problem. However, in some cases of DAI (diffuse axonal injury) where there is loss of grey and white matter differentiation with other evidences of raised ICP there is usually differing opinions on the best way to manage.
Do any of the readers have any strategy, thoughts or experience in dealing with this group of patients. Does your department have any guidelines on emergent management of raised ICP where surgical intervention may not be indicated (barring insertion of ICP bolt)!
The modalities available here for the situation you have outlined include IV mannitol, oral glycerol (via NG tube), dexamethasone & hyperventilation. The choice of intervention depends not only on individual patients but also on the neurosurgeon involved.
What is your suggestion? What does your ED protocol day?
There is no clear consensus on this in our ED. I start of with simple measures like
a. loosening the semirigid neck collar (but ensuring that the patient doesn't move his head!) but with the blocks and tape still on
b. 15-30 degrees 'head end up' position once other significant spinal injuries are ruled out
c. Between Mannitol and hypertonic saline, we've used them occassionally (more so after the patient shows signs of uncal herniation). We now have stopped using hypertonic saline (after the major trial that was being done in US has been stopped rather prematurely as initial results showed no benefits!!! This was just a few months ago...)
d. we have never used Oral Glycerol. I have also never used dexamethasone for head injuries though I've used it for spinal cord injuries.
e. Used Barbiturates once for this purpose. But our patient had a good blood pressure. I would have thought twice (or not even consider) if he was hypotensive...
f. Most importantly, I make sure that the patient has a continous EtCO2 monitoring on and aim to keep it tightly between 4 - 4.5 kPa
g. Maintain normoglycaemia and normothermia
Issues for me are mainly around Mannitol/Hypertonic saline, Barbiturates and steroids as it is never too clear....
