There are certainly several interventions that can help in the acute settings while awaiting for definitive solution (surgery):
1. Elevation of the head of the bed (30-45 degrees)
2. Hyperventilation - in the setting of acute herniation (Cushing triad + blown pupil) - just use BVM and hyperventilate (until pupil constricts). Long term, most guidelines recommend maintaining PCO2 of 30-35 (lower pco2 can cause too much cerebral vasoconstriction...)
3. Mannitol vs 3% NS :
There are several advantages to 3% NS over Mannitol :
- 3% can be given very fast (most guidelines recommend 5-10 ml/kg/min over 5-10 min, which basically means 1cc/kg/min) while Mannitol is usually given over 20 minutes
- Mannitol causes diuresis that may result in drop in systemic BP (which is important in the setting of ICP to maintain CPP)
- meta-analysis showed that 3% was slightly better than Mannitol
For Mannitol the dose is 0.5-1 gr/kg.
4. Eliminate and stop anything that increases metabolic demand :
- treat fever
- treat agitation ( sedation / intubation)
- stop seizures as soon as you can.
My clinical experience with 3% NS with several patients that presented with classic Cushing triad and acute herniation was good so far with fast response.
Ehud Rosenbloom MD
Division of Pediatric Emergency Medicine
Department of Pediatrics
McMaster Children's Hospital
On 2013-10-16, at 4:34 PM, Marc Guttman <[log in to unmask]> wrote:
> Other than rapid surgical decompression, is there any other recommended intervention for significant bradycardia from a Cushing Response in the setting of increased ICP/herniation secondary to traumatic intracranial hemorrhage while waiting (hopefully very shortly) for neurosurgical intervention?
> For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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