RAISED INTRACRANIAL PRESSURE Phenytoin is used to prevent or control seizure activity that

Causes increases cerebral blood flow and subsequently intracranial

A.Trauma pressure. Anticonvulsant medications should be used for 1 week
1) Haematoma-epidural,subdural,intraventricular, following injury and then discontinued if seizures are not
subarachnoid hemorrhage recurrent.
2) Cerebral edema 5. Nimodipine
3) Depressed skull fractures The calcium channel blocker reduces death and severe
B. Infections disability when instituted acutely in patients with head injuries
1) Bacterial-Staphylococcus, streptococcus, 6. Sedatives
Haemophilus, tuberculous meningitis. High dose diazepam may be considered for hemodynamically
2) Parasitic-Cysticercosis, Toxoplasmosis, Echinococcus stable, salvageable, severe head injury patients with intracranial
3) Fungal-Cryptococcus, histoplasmosis Aspergilosis hypertension refractory to maximal medical and surgical
4) Intracranial Abscesses therapy. Other narcotics may depress respiration.
C. Neoplastic causes 7. Relieve and prevent pyrexia
1. Neuroepithelial tumors; glioma. This increases intracranial pressure. E.g. NSAIDS Provision of
 Astrocytoma. .analgesia has similar effects
 Astroblastoma. 8. Steroids
Dexamethasone use is controversial in head injury
 Choroid glioma.
9. Hyperventilation
 Ependymoma To blow out the co2 and reduce hypercapnia and keep the
 Oligodendroglioma. partial pressure of co2 between 30-40 mmHg.
2. Pineal region tumors; pineoblastoma. The use of prophylactic hyperventilation (PaCO2 < 35 mm Hg)
3. Neuronal and mixed glial tumors therapy during the first 24 hours after severe TBI should be
4. Embryonal tumors; medulloblastoma. avoided because it can compromise cerebral perfusion during a
5. Meningeal tumors; meningioma. time when cerebral blood flow (CBF) is reduced.
6. Peripheral neuroblastic tumors; neuroblastoma. Hyperventilation therapy may be necessary for brief periods
7. Lymphoma and hemopoietic tumors; microglioma. when there is acute neurologic deterioration, or for longer
8. Germ cell tumors; germinoma. periods if there is intracranial hypertension refractory to
9. Tumors of cranial and spinal nerves; neurofibroma. sedation, paralysis, cerebrospinal fluid (CSF) drainage, and
10. Metasases; lung, breast, thyroid, renal etc. osmotic diuretics.
D.Metabolic
1. Electrolyte imbalances-hyponatriemia
2. Hypoventilation-hypercapnia.
E.Others
1) Hypertension
2) Hydrocephalus
3) Dural sinus thrombosis
4) ARDS
5) Seizures and convulsions

MANAGEMENT
Symptoms
1) -Severe bursting headache
2) -Projectile vomiting
3) -Blurring of vision
4) -Convulsions/seizures
5) -Drowsiness
Signs
1) -Vital signs-increased BP and decreased pulse rate
(cushings reflex)
2) -Anisocoria-unequal pupils
3) -Papilloedema on fundoscopy
4) -Nerve palsy e g 3rd and 6th cranial nerves
5) -Tense fontanels.
6) -Irregular breathing/slowed fats

Parameters: Normal ICP = 0-10 mmHg.

Treatment threshold > 20-25 mmHg.
Goal CPP = 60-70 mmHg.

1. Elevation of head
To promote venous drainage from the head.
2.Ventilation o2 by mask
Prevention of hypoxia and hypercapnia which increase ICP
3. Mannitol.
i. Effective doses range from 0.25-1 gram/kg, given by
intermittent bolus infusion every 4-6 hrs.
ii. Euvolemia must be maintained.
iii. Monitor osmolality. Do not exceed 320mOsm/kg
4. Anticonvulsant therapy

JUDY WAWIRA GICHOYA yr 2007 1