Table 2: Summary of measures to control IC-HTN a Goals: Keep ICP < 22 mm Hg, and CPP ≥ 50 mm Hg

Skill Done Sufficiently (2) Done Insufficiently (1) Not Done (0)
General measures (should be utilized routinely)
Elevate head of the bed by 30 °C
Keep neck straight, avoid neck constrictions (tight trach tape, tight cervical collar...)
Control hypertension if present
Avoid arterial hypotension (SBP < 90 mm Hg)
Avoid hypoxia (PaO2 < 60 mm Hg or O2 sat < 90%)
Ventilate to normocarbia (PaCO2 = 35-40 mm Hg)
Light sedation: e.g. codeine 30-60 mg IM q 4 hrs PRN
Perform unenhanced head CT scan to identify etiology
Specific measures for ICH (proceed to successive steps if documented ICH persists - each step is ADDED to the previous measure)
Heavy sedation (e.g. fentanyl 1-2 ml or morphine 2-4 mg IV q 1 hr) and/or paralysis (e.g. vecuronium 8-10 mg IV)
Drain 3-5 ml CSF if intraventricular catheter is present
Hyperventilate to PaCO2 = 30-35 mm Hg ("blows off" CO2 )
Mannitol 0.25-1 gm/kg, then 0.25 gm/kg q 6 hrs, increase dose if ICH persists & serum osmol ≤ 320 (NB: Skip this step if hypovolemia or hypotension)
If there is "osmotic room" (i.e., serum osmol < 320) bolus with 10-20 ml of 23.4% hypertonic saline
Augmented hyperventilation to ↓ PaCO2 to 25-30 mm Hg
If ICH persists, consider unenhanced head CT & EEG. Proceed to "second tier" therapy