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Frequently bolus of 3%hts 5 ml/kg per peripheral IV  keeping Na < 160
monitoring response by HR and keeping Ratio of ETCO2 to pVCO2 narrow and less than 30 mmHg, etomidate ( decrease cerebral metabolism) until neurosurgery arrives is alternative 
If you have capability ofcerebral oximetry ( usually in or or ICU) place probes on left and right forehead it  is a great monitoring tool for increase ICP and response to therapy

Detecting ICP  changes occur faster than global vital signs with cerebral oximetry.
Tom Abramo

Sent from my iPhone

> On Oct 16, 2013, at 6:57 PM, "Prater, Samuel J" <[log in to unmask]> wrote:
> 
> Standard dose of 3% is 5 mL/kg, however you really don't need 3%. Most places routinely have sodium bicarbonate in their crash carts, code boxes, etc.
> 
> 2 mEq/kg of sodium bicarbonate is an acceptable alternative to 3% (and often easier to get).
> 
> Sent from my iPhone. Please excuse misspellings and grammar errors.
> 
> Samuel J. Prater, M.D.
> Assistant Professor of Emergency Medicine
> UT Medical School at Houston
> Medical Director of Emergency Services
> Memorial Hermann Hospital-TMC
> 832-407-3108
> 
> On Oct 16, 2013, at 6:02 PM, "marc guttman" <[log in to unmask]<mailto:[log in to unmask]>> wrote:
> 
> Thanks, Michael and Alice.
> 
> My understanding of mannitol is that it is generally recommended for treatment of elevated ICP from cellular and vasogenic edema, that it does reduce ICP, but we are without evidence as of now of whether it results in improved clinical outcomes.  Again, still recommended.  For emergent intervention, in the patient with rapid neurologic deterioration, do you recommend a bolus of 1g/kg.
> 
> Do you use mannitol and hypertonic saline?  I understood it to be one or the other with no clear benefit of one over the other, although small studies suggested slight benefit of hypertonic saline over mannitol.  What volume boluses of 3% saline do you use?
> 
> 
> Thanks again.
> 
> Best,
> Marc
> 
> www.WeDiscover.net<http://www.WeDiscover.net>
> 
> 
> ________________________________
> From: Michael Verive <[log in to unmask]<mailto:[log in to unmask]>>
> To: [log in to unmask]<mailto:[log in to unmask]>
> Sent: Wednesday, October 16, 2013 5:53 PM
> Subject: Re: Cushing Response
> 
> 
> Yes - hyperventilation, mannitol, 3% hypertonic saline.
> 
> Michael Verive, MD, FAAP
> 
> Sent from my iPhone
> 
> 
> On Oct 16, 2013, at 3:34 PM, Marc Guttman <[log in to unmask]<mailto:[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?
> 
> Thanks.
> 
> Best,
> Marc
> 
> www.WeDiscover.net<http://www.WeDiscover.net>
> 
> 
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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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