Management of increased ICP (Crain. Clinical Manual of Emergency Pediatrics. 3rd. Ed)

• If GCS < 9 or a falling GCS after head trauma, evaluate for intracranial hypertension
• If increased ICP is suspected:
  • Call neurosurgery and neurology
  • CR monitor, Access, ABG to assess adequacy of ventilation
  • If hypotensive, this takes priority over treatment of increased ICP
  • Always keep patients head in midline and elevated head of bed 40 degrees
  • Give 100% O2
  • Reasons to intubate: hypoxia, hypercarbia (PCO2 >40), stuporous, comatose, or leaving the ED/floor for a diagnostic procedure
• If markedly increased ICP (unequal pupils, bradycardia, hypertension, posturing), lower ICP immediately
  • immediate intubation and hyperventilate to 25 to 30 mm Hg pCO2
    • make sure not hypotensive
    • sedative: thiopental 3-5 mg/kg IV, flush w/ NS (use 1-2 mg/kg if hypotensive)
    • paralytic: vecuronium 0.1 mg/kg IV (onset 30 s, peak effect 3-4 min)
    • cricoid pressure and intubation
    • NG tube, aspirate stomach contents, to suction
  • IV mannitol 0.5 to 1 g/kg, and insert a foley catheter
  • dexamethasone 0.2 mg/kg up to 16 mg (if mass lesion is suspected)

For extended discussion, see Increased ICP, Central hyperventilation