Relieving Intracranial Pressure with adaptive thinking

[Doc Skittles]

How would one go about relieving intracranial pressure in a casualty in a feild type setting where what you have in your aidbag is what you have to work with? Question asked because i am personally curious and want to be prepared if i am ever in this situation down range

[swatsurgeon]

The first question to be asked is how would you make the diagnosis of intracranial hypertension? There are a few injuries that do not fair well in the field relative to our ability to intervene and this is one of them. Extricate /casevac are the maneuvers that can make a difference. The average medic/PA or field doc will not have the necessary tools to diagnose or treat this. Preventing secondary injury: prevent hypotension and prevent hypoxia are difficult at best in the field to deal with...haven't seen too many oxygen bottles being carried by anyone.
Get them out of there and to a medical facility is the best field medicine...and prevent further injuries from occuring/deal with other injuries, etc.

ss

[Doc Skittles]

evac,roger. thank you ss

[beefpops]

Diagnosing increased ICP is not something you can do with accuracy in the field, and the only definitive treatment is echelons above the aid bag. Mechanism of injury, length of unconsciousness, AMS/GCS, unequal pupils, CSF, yes, but these aren't enough to truly make a determination. Err on the side of caution with head wounds and always, always, always remember that you can't fix a swollen brain.
The vicious cycle of increased ICP is this: Injury>Swelling>increased ICP>decreased perfusion to brain>further injury, repeat until dead. There are several methods used to treat increased ICP that are unfeasible in the field. We can rule out cranial surgery (it's a little tricky).

LASIX is used by some civilian medics, but it also decreases cardiac output. A major component to the aggravation of ICP is inadequate perfusion, so this seems counterintuitive.

STEROIDS are used (mostly in Europe if I recall correctly) to treat acute head trauma, but statistically they increase the death rate of patients. Even if steroids help with the increased ICP, they cause complications further down the road, so again, no dice.

MANNTOL is used by some flight medics. It's an unprocessable sugar that dehydrates the tissues and is then passed. However, it can only be administered once effectively. Once it wears off, the swelling returns with a vengeance. Because of this, it's only recommended when the medic knows that the patient will be on a surgical table before the mannitol wears off, again not a guarantee that a medic on the front lines can make.

HYPERVENTILATION Civilian EMTs were once taught to hyperventilate head trauma patients. This can actually work, but there has to be a perfect rate of gas exchange occuring for this method to reduce ICP. I'm not sure about the exact science behind this, but the real problem is that if the patient is ventilated too quickly by just a little, it can further aggravate ICP. Unless you have a CO2 monitor and an expert knowledge of this method, it's nothing to rely on, and can even worsen your patient's condition.

So there's a big list of don'ts. Dos are a little more rare. The first DO for increased ICP is to treat for shock. Again, inadequate perfusion will worsen the increased ICP, and shock is more likely to kill your patient than increased ICP. If you've got it, high flow 02 never killed anyone who wasn't smoking.
Since the head is the highest point on the body, the veins returning from the head are relatively low pressure. You can relieve some of the pressure by elevating the head above the patient's heart.
I've also learned to hold off on large volumes of IV fluids. Of course, this (as well as everything else here) does NOT take priority over treating bleeding, shock, etc.

The takeaway from this: Treat for shock, sit em up, easy on the fluids. Above all, get them to somebody who can really help them!
Skip the lasix, mannitol, steroids, and hyperventilation.

[swatsurgeon]

beefpops,
i question the reasoning you posted the above information...your area of expertise is what field of medicine? did you not read the post above from me? A lot of words do not make for academic excellence nor better advice. Adding information to the discussion that would assist the field operator is always welcomed...your explanation offered no such increase in information from my review.
We welcome contributions that are well thought out, accurate, timely and appropriate for the discussion at hand. Please do not post just to display words which is what you just did. Be mindful of the level of expertise of other posts....differences of opinion are good, restating in a more generic fashion is a waste of time.
For a second post one would consider watching, reading, learning and eventually posting when the words have value or opinion, not reiteration especially in things medical...please post an expanded view of another post but not a restatement of one.

ss

[beefpops]

Sorry for the post without much background information. My area of medical expertise is relatively limited as a 68W with some additional training (DMI's OEMS course along with miscellaneous training that the 82nd put me through). As a line medic, I was always very interested in finding out what the best I could do in a given situation would be. I asked the same question as the original poster to Dr. John Hagmann about a year ago on this exact topic, and I took a lot of notes. All of the scholarly mumbo jumbo above is from his mouth, and he was very clear when he explained that the most important thing to remember is that shock treatment and evac really are the best things that a medic can do. He's a great teacher, and he was very sure to communicate to me that we aren't being sent into combat with below standard techniques and procedures.
The main point of the above information is that although there are a lot of techniques and drugs available for the treatment of increased ICP, there isn't a whole lot available to the combat medic.

[Paramedic40]

As far as I know, in a field setting (even with ALS protocols and equipment) the only thing we can do to manage brain injuries is to support life functions. Some systems allow Mannitol, but from what I remember, it seemed to be going out-of-favor (this from my own recollection, my father, a 20-year paramedic) and my paramedic instructor). Like Swatsurgeon said, we can't actually measure ICP in the field, even based on mechanism of injury or mental status, because we have no way of knowing whether any deficits or abnormalities are being caused by increasing intracranial pressure or hypoxia, tissue damage, or even psychomotor causes. If we see something like Cushing's Triad (increased BP, decreased pulse, and irregular respirations) or deteriorating mentation/LoC/GCS, we can presume that they've sustained some insult to their brain that may be swelling- but will this actually change any of our treatments? Remember that we're already limited in what we can give/do by the nature of the injury.

1. Rapid Evac: As with all other emergent trauma, we can't help anything, at any level, in the field (even if you're a surgeon, working out of an aid bag isn't going to help).
2. BLS (support the airway, manage breathing/ventilations)
3. C-Spine/Immobilization! I was taught this simple mantra: If it's hard enough to knock them out, you need to control where they're going. If we're looking at some sort of gross deficit, we need to have them fully immobilized, because we have no way of knowing what the cranial vault's integrity is like, even with palpation.
4. IV access, fluids to maintain BP. I was taught by the Army to run fluids to keep a radial pulse. My civilian training was to keep their BP even lower (80-90mm systolic). I do have a question on Hextend- the Army told me it was indicated, civilian world said stick to NS for this. I would imagine that it could help by drawing off interstitial fluid/edema- but I am unsure and would like a second opinion.
5. If we're going to medicate, do it in accordance with SOPs and protocols. I personally was taught (civilian-side) not to use analgesics if we can't see the bleed, and I agree. If my SOPs allow me to push Mannitol and I know that a patient will be in the hands of a surgical team within a half-hour or so, I would give it if I felt it to be in the patient's benefit, but in general terms, I don't see a real need to go pushing meds into trauma patients. IV fluids should be very closely monitored and considered, and we should be mindful of positioning.
6. REASSESS! We must continuously monitor a patient with injuries that we suspect to have caused increases in ICP. In a MASCAL, unfortunately, this patient might be triaged to expectant, but if at all possible, we should get them out ASAP.

The sad fact is that there's no magic procedure or tool in any field provider's bag to manage increasing intracranial pressure. We can't evacuate the cranial vault, we can't puncture, drain, or remove it, and we can't medicate it away for very long. The only thing we can do is to get them somewhere that has people who can.

[Cynic]

Butting in as an old neuro-surgical nurse, NOT an EMT or medic; we were taught that -
"The brain is surrounded by a membrane separating it from the vascular space - the blood-brain barrier. This membrane will only allow water to pass through it. Therefore only fluid with the same concentration of sodium as plasma should be given intravenously. Otherwise, the plasma will become more dilute and water will pass from it into the brain, making the brain swell, and thus increase pressure further.

Normal Saline (0.9%) has a similar concentration of sodium and therefore is the fluid of choice for the brain. When Dextrose solutions in water (5% Dextrose, Dextrose 4%-Saline 0.18%) are given, the dextrose is metabolized leaving just the water or a very dilute saline solution. This "dilutes" the blood, reducing the concentration of sodium in the plasma. The water then passes into the brain where the concentration of sodium is higher. The brain then swells, and intracranial pressure will rise."

Long story short, when in doubt with ICP, don't use glucose.

I would like to hear Swatsurgeon's suggestion for in the field IV solution choice, and do combat medics carry a choice of IV solution?

Curious and back to lurking.
- C.

[SAXON 88]

I tell my paramedics A, B, C, D. What does D stand for?

DIESEL!

[PedOncoDoc]

I tell my paramedics A, B, C, D. What does D stand for?

DIESEL!

And I thought D was disability followed by E for exposure....Maybe you could switch to F foor Floor it! ;)

[whocares175]

when it comes to iicp the biggest things we're taught at the school house are:
1-recognize injuries that would raise your level of suspicion for iicp
2-treat all other inj's to prevent shock
3-EVAC ASAP
4-while mannitol MAY be helpful, most of the patients we'll probably see with iicp are trauma patients who are suffering the effects of hypovolemia already, not a good idea to mix diuretics with hypovolemia
5-if you have to hang on to a patient for a while refer back to steps 1 & 2 also, you can try elevating the head above the level of heart and hyperventilation (supplies more O2 to the blood thus reducing the size of the arteries in the brain and hopefully relieving pressure)
6-EVAC ASAP-did i say that before? good.
the things mentioned in step 5 are only temporary to TRY and SLOW down iicp. the bottom line is as a field medic you can't deal with iicp. get the patient to higher echelons of care.

[Red Flag 1]

And I thought D was disability followed by E for exposure....Maybe you could switch to F foor Floor it! ;)

I could see a clear link to "J".....as in JP 4 or 5 ( air-evac gas). F works fine as well.

Hydration...NS and rapid transport. O2 en-route will help if the diagnosis of ICP is correct.

Agree with SS and Saxon.

My $.02.

RF 1

[Decoy_Octopus]

The first question to be asked is how would you make the diagnosis of intracranial hypertension? There are a few injuries that do not fair well in the field relative to our ability to intervene and this is one of them. Extricate /casevac are the maneuvers that can make a difference. The average medic/PA or field doc will not have the necessary tools to diagnose or treat this. Preventing secondary injury: prevent hypotension and prevent hypoxia are difficult at best in the field to deal with...haven't seen too many oxygen bottles being carried by anyone.
Get them out of there and to a medical facility is the best field medicine...and prevent further injuries from occuring/deal with other injuries, etc.

ss

Cushings triad

[Guy]

Diagnosing increased ICP is not something you can do with accuracy in the field, and the only definitive treatment is echelons above the aid bag. Mechanism of injury, length of unconsciousness, AMS/GCS, unequal pupils, CSF, yes, but these aren't enough to truly make a determination. Err on the side of caution with head wounds and always, always, always remember that you can't fix a swollen brain.
The vicious cycle of increased ICP is this: Injury>Swelling>increased ICP>decreased perfusion to brain>further injury, repeat until dead. There are several methods used to treat increased ICP that are unfeasible in the field. We can rule out cranial surgery (it's a little tricky).

LASIX is used by some civilian medics, but it also decreases cardiac output. A major component to the aggravation of ICP is inadequate perfusion, so this seems counterintuitive.

STEROIDS are used (mostly in Europe if I recall correctly) to treat acute head trauma, but statistically they increase the death rate of patients. Even if steroids help with the increased ICP, they cause complications further down the road, so again, no dice.

MANNTOL is used by some flight medics. It's an unprocessable sugar that dehydrates the tissues and is then passed. However, it can only be administered once effectively. Once it wears off, the swelling returns with a vengeance. Because of this, it's only recommended when the medic knows that the patient will be on a surgical table before the mannitol wears off, again not a guarantee that a medic on the front lines can make.

HYPERVENTILATION Civilian EMTs were once taught to hyperventilate head trauma patients. This can actually work, but there has to be a perfect rate of gas exchange occuring for this method to reduce ICP. I'm not sure about the exact science behind this, but the real problem is that if the patient is ventilated too quickly by just a little, it can further aggravate ICP. Unless you have a CO2 monitor and an expert knowledge of this method, it's nothing to rely on, and can even worsen your patient's condition.

So there's a big list of don'ts. Dos are a little more rare. The first DO for increased ICP is to treat for shock. Again, inadequate perfusion will worsen the increased ICP, and shock is more likely to kill your patient than increased ICP. If you've got it, high flow 02 never killed anyone who wasn't smoking.
Since the head is the highest point on the body, the veins returning from the head are relatively low pressure. You can relieve some of the pressure by elevating the head above the patient's heart.
I've also learned to hold off on large volumes of IV fluids. Of course, this (as well as everything else here) does NOT take priority over treating bleeding, shock, etc.

The takeaway from this: Treat for shock, sit em up, easy on the fluids. Above all, get them to somebody who can really help them!
Skip the lasix, mannitol, steroids, and hyperventilation.90% of stuff you just wrote, you won't remember (that school house rhetoric) when the proverbial "shit-hits-fan!"

Stay safe.