Professional Soldiers ® - View Single Post - Relieving Intracranial Pressure with adaptive thinking

beefpops · 04-15-2010, 20:37

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.

04-15-2010, 20:37	#4
beefpops Asset Join Date: Apr 2010 Location: Northern Bay Area, CA Posts: 0	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.
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