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!!!!