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Elevated intracranial pressure (ICP), defined as >20mmHg, is frequently encountered in patients with severe traumatic brain injury (TBI). A step-wise approach would include:
1. Analgesia and sedation: frequently forgotten.
2. Hyperosmolar agents: both hypertonic saline and mannitol can be used. Neither is superior.
3. Induced arterial blood hypocarbia using hyperventilation (must monitor for cerebral ischemia)
4. Barbiturates (last resort due to side effects)
5. Surgical:
a. CSF drain
b. Decompressive craniectomy: benefits challenged by the DECRA study
Stocchetti N, Maas AIR. Traumatic Intracranial Hypertension. N Engl J Med 2014; 370:2121-30.