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.

[Guy]

Originally Posted by 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.

90% of stuff you just wrote, you won't remember (that school house rhetoric) when the proverbial "shit-hits-fan!"

Stay safe.

[Decoy_Octopus]

Originally Posted by 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

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