Medication Summary
Medical therapy is directed at controlling intracranial pressure (ICP) through the administration of sedatives and neuromuscular blockers, diuretics, and anticonvulsants.
Neuromuscular Blockers, Nondepolarizing
Class Summary
Nondepolarizing neuromuscular blockers are used in combination with a sedative as part of the rapid-sequence intubation process or as a means of controlling ICP.
Vecuronium
Vecuronium is used to facilitate endotracheal intubation and provide neuromuscular relaxation during intubation and mechanical ventilation. It is given as an adjunct to a sedative or hypnotic agent.
Anticonvulsants, Barbiturates
Class Summary
Barbiturates are used as adjuncts for intubation in patients with head trauma and in the management of elevated ICP. They may also be used as anticonvulsants. Their use must be accompanied by appropriate hemodynamic monitoring, as they may cause profound hypotension and apnea/hypopnea.
Pentobarbital (Nembutal)
Pentobarbital is a short-acting barbiturate with sedative, hypnotic, and anticonvulsant properties. It may be used in high dosages to induce barbiturate coma for treatment of refractory increased ICP.
Phenobarbital
Phenobarbital is used for seizure control in patients with head trauma.
Anxiolytics, Benzodiazepines
Class Summary
Benzodiazepines may be used to obtain immediate control of seizure activity or as adjuncts to narcotics and neuromuscular blockers for control of ICP. Prolonged use of these drugs may alter neurologic examination findings.
Midazolam
Midazolam is a short-acting benzodiazepine with a rapid onset of action. It is useful in treating increased ICP.
Lorazepam (Ativan)
Lorazepam is a long-acting benzodiazepine used as an anticonvulsant for the immediate control of seizure activity.
Diuretics
Class Summary
Diuretics may have a beneficial effect in lowering ICP by decreasing cerebrospinal fluid (CSF) production, preferentially excreting water over solute, and decreasing blood viscosity, with subsequent improvement of cerebral blood flow (CBF).
Furosemide (Lasix)
Furosemide is a loop diuretic that helps decrease ICP via 2 separate mechanisms. One mechanism influences CSF formation by affecting sodium-water movement across the blood-brain barrier; the other mechanism is the preferential excretion of water over solute in the distal tubule.
Mannitol (Osmitrol)
Mannitol is an osmotic diuretic that lowers blood viscosity and produces cerebral vasoconstriction with normal CBF. A decrease in ICP occurs subsequent to a decrease in cerebral blood volume (CBV).
Anesthetics
Class Summary
These agents may be used to control ICP by decreasing the effect of noxious stimuli (eg, endotracheal intubation, suctioning, pain from traumatic injury itself). Although lidocaine has been widely used in the past to blunt transient increases in ICP during endotracheal intubation, there is no high-level evidence to support its continued use for this purpose. [45]
Fentanyl (Sublimaze)
Fentanyl is a potent synthetic opioid with a rapid onset and short duration of action. Although an opioid, fentanyl produces only mild sedation at usual doses, and it is commonly used in combination with a benzodiazepine.
Propofol (Diprivan)
Propofol is an oil-soluble hypnotic agent with a rapid onset and short duration of action. Because propofol has limited anesthetic action, it is usually used with an opioid such as fentanyl for painful procedures. Propofol use is associated with hypotension, bradycardia, and apnea, especially when boluses are given for induction of anesthesia. Because of its short duration of action, propofol infusions may be discontinued briefly to allow neurologic testing, and then restarted (with or without bolus) to resume sedation.
Anticonvulsants
Class Summary
Anticonvulsants are recommended as a prophylactic measure for patients at increased risk for seizure activity after head trauma. No proof exists of a beneficial effect in seizure prevention more than 1 week after head trauma. These agents are also used for immediate control of seizures.
Phenytoin (Dilantin, Phenytek)
Phenytoin may act in the motor cortex, where it may inhibit the spread of seizure activity. It may also inhibit the activity of the brainstem centers responsible for the tonic phase of grand mal seizures. Phenytoin is preferred to phenobarbital for controlling seizures because it does not cause as much central nervous system (CNS) depression.
Fosphenytoin (Cerebyx, ProEpanutin)
Fosphenytoin is a diphosphate ester salt of phenytoin that acts as a water-soluble pro-drug of phenytoin. Following administration, plasma esterases convert fosphenytoin to phosphate, formaldehyde, and phenytoin. Phenytoin, in turn, stabilizes neuronal membranes and decreases seizure activity.
To avoid the need to perform molecular weight–based adjustments when converting between fosphenytoin and phenytoin sodium doses, express dose as phenytoin sodium equivalents (PE). Although fosphenytoin can be administered IV and IM, the IV route is the route of choice and should be used in emergency situations.
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Pediatric Head Trauma. Epidural hematoma with midline shift.
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Pediatric Head Trauma. Subdural hematoma.
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Pediatric Head Trauma. Intraventricular hemorrhage.
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Pediatric Head Trauma. Epidural hematoma with acute neurologic deterioration.
Tables
Score |
≥1 Year |
0-1 Year |
4 |
Opens eyes spontaneously |
Opens eyes spontaneously |
3 |
Opens eyes to a verbal command |
Opens eyes to a shout |
2 |
Opens eyes in response to pain |
Opens eyes in response to pain |
1 |
No response |
No response |
Score |
≥1 Year |
0-1 Year |
6 |
Obeys command |
N/A |
5 |
Localizes pain |
Localizes pain |
4 |
Flexion withdrawal |
Flexion withdrawal |
3 |
Flexion abnormal (decorticate) |
Flexion abnormal (decorticate) |
2 |
Extension (decerebrate) |
Extension (decerebrate) |
1 |
No response |
No response |
Score |
> 5 Years |
2-5 Years |
0-2 Years |
5 |
Oriented and able to converse |
Uses appropriate words |
Cries appropriately |
4 |
Disoriented and able to converse |
Uses inappropriate words |
Cries |
3 |
Uses inappropriate words |
Cries and/or screams |
Cries and/or screams inappropriately |
2 |
Makes incomprehensible sounds |
Grunts |
Grunts |
1 |
No response |
No response |
No response |
