Hawryluk, G.W.J., Aguilera, S., Buki, A. et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 45, 1783–1794 (2019). https://doi.org/10.1007/s00134-019-05805-9

Tier ZERO – Basic neuroprotective care, irrespective of ICP

• Mandatory
  • Elevate head of bed 30-45^o
  • Optimise cranial venous drainage
  • Analgesia for pain
  • Sedation to prevent agitation/ventilator asynchrony
  • Fever prevention
  • Hb >70
  • Avoid hyponatraemia
  • Sat >= 94%
  • CPP >=60
  • Art line
• Recommended
  • CVC
  • ETCO₂ monitoring

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Tier ONE ICP-lowering techniques

Targets

• CPP 60-70 mmHg
• Na⁺ =< 155
• Osmolality (serum) =<320 mEq/L
• PaCO₂ 35-38mmHg

Actions

• Increase analgesia
• Increase sedation
• Mannitol (0.25/1.0 g/kg) or hypertonic saline intermittent boluses (within Na/Osm limits above)
• Drain CSF via EVD (or consider EVD placement as appropriate)
• Consider seizure prophylaxis
• Consider EEG monitoring

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Tier TWO ICP-lowering techniques

Targets as above, except:

• PaCO₂ 32-35mmHg

Actions

• NMB in adequately sedated patients. Continue only if first dose efficacious
• MAP Challenge
  • Raise MAP by 10mmHg for <20mins (using vasoactive)
  • IF ICP remains the same, autoregulation is intact.
• IF autoregulation intact – raise CPP with fluid/vasopressors/inotropes

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Tier THREE ICP-lowering techniques

Targets as above, except:

• Mild hypothermia (T 35-36^oC)

Actions

• Barbiturate coma (Pentobarbital or Thiopentone) – only continue if efficacious
• Active cooling to target temp above
• Secondary decompressive craniectomy

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Note:

Use the lowest possible tier when possible, but tiers may be skipped if appropriate to the urgency of the situation.

At each stage, consider extracranial causes of ICP, the metabolic milieu and general physical parameters.

Consult appropriately.