Increased Intracranial Pressure (ICP) in Trauma: "EM in 5"

Summary

This video script addresses increased intracranial pressure due to trauma, a common emergency room scenario. It emphasizes the critical '90s rule for vital signs: maintaining oxygen saturation above 90% and systolic blood pressure above 90 mmHg to prevent a two to threefold increase in mortality. The script reviews causes, such as blunt injuries and gunshot wounds, and management strategies including airway maintenance, head elevation, and medication like mannitol and CPPA for seizure prevention. It also discusses the cushion reflex as an indicator of increased ICP.

Takeaways

• 🏥 Increased intracranial pressure is a common issue in trauma patients coming to the ER.
• 🚑 Trauma, including blunt injury and gunshot wounds, can lead to increased intracranial pressure.
• 🧠 The brain needs oxygen and perfusion to prevent secondary injury; hypoxia and hypotension increase mortality.
• 🌡️ Oxygen saturation should be kept above 90% to prevent increased mortality.
• 🩸 Systolic blood pressure should be maintained above 90 mmHg to ensure adequate brain perfusion.
• 🏋️‍♂️ Hypertension, bradycardia, and irregular breathing are signs of increased intracranial pressure.
• 💊 Mannitol (1 gram per kilogram) and CPPA (1 gram) are key medications for managing increased intracranial pressure.
• 💉 Lidocaine is used for pre-treatment in patients with head trauma, with a dose of 1 milligram per kilogram IV.
• 🛏️ Elevating the head of the bed helps optimize perfusion status.
• 🧪 Cerebral Perfusion Pressure (CPP) is calculated as MAP minus ICP, with a goal of 50 to 70.
• 💊 Prophylactic treatment for seizures in the first seven days post-injury is important.

Q & A

What is the primary focus of today's EM and 5 talk?

The primary focus is on increased intracranial pressure and trauma, specifically discussing how to manage such cases in the ER to improve patient outcomes.

What are the 'three to remember' numbers mentioned in the talk?

The 'three to remember' numbers are related to vital signs and medications. For vital signs, the numbers are '90s', which refer to keeping oxygen saturation above 90% and systolic blood pressure above 90 mmHg. For medications, it's the 'ones', referring to dosing of certain drugs like 1 gram per kilogram.

What types of injuries can cause increased intracranial pressure?

Injuries that can cause increased intracranial pressure include blunt injuries such as subarachnoid hemorrhage, epidural hemorrhage, skull fractures, intraventricular hemorrhage, and diffuse axonal injury. Gunshot wounds, which have a high mortality rate, can also cause increased intracranial pressure.

Why is it crucial to prevent hypoxia in patients with head trauma?

Preventing hypoxia is crucial because if oxygen saturation goes below 90% even once, it can increase the mortality rate by two times.

How important is maintaining proper perfusion in head trauma patients?

Proper perfusion is vital as a systolic blood pressure dip below 90 mmHg even once can increase mortality by three times.

What are the two major things that need to be managed in the ER to prevent secondary injury in head trauma patients?

The two major things to manage are ensuring adequate oxygenation to prevent hypoxia and maintaining proper perfusion to prevent systemic hypotension.

What is the cushion reflex and why is it important in cases of increased intracranial pressure?

The cushion reflex, also known as Cushing's reflex, is a late sign of increased intracranial pressure. It includes hypertension, bradycardia, and irregular breathing or apnea, indicating pressure on the brainstem, which could lead to herniation or death.

What is the goal for the partial pressure of arterial carbon dioxide (PaCO2) when managing head trauma patients?

The goal for PaCO2 is to maintain it around 35 mmHg to prevent hypercapnea without causing hyperventilation, which can drive the CO2 too low.

What is the equation for cerebral perfusion pressure (CPP) and what is the target range?

The equation for CPP is CPP = MAP - ICP, where MAP is the mean arterial pressure and ICP is the intracranial pressure. The target range for CPP is 50 to 70 mmHg.

What are the two treatment medications mentioned for managing increased intracranial pressure?

The two treatment medications are mannitol, dosed at 1 gram per kilogram IV, and丙戊酸钠 (sodium valproate), also dosed at 1 gram IV.

Why is it important to treat patients with head trauma for early seizures?

Early seizures can occur within the first seven days post-injury, and treating them helps prevent further neurological damage.