Raised ICP Management
Normal ICP: 5–15 mmHg. Treat if ICP > 20 mmHg. Target CPP (MAP − ICP) ≥ 60 mmHg.
Stepwise ICP reduction
- Head of bed 30°; neutral head position; avoid constrictive neck dressings
- Target PaCO2 35–40 mmHg (avoid hypo/hyperventilation)
- Sedation + analgesia: propofol/midazolam + fentanyl; avoid coughing/agitation
- Mannitol 0.5–1g/kg IV bolus (20% solution); target serum osm < 320; maintain normovolaemia
- Hypertonic saline 3% 250ml or 23.4% 30ml for acute spikes (target Na 145–155)
- Temperature control: target normothermia (37°C); avoid fever aggressively
- Decompressive craniectomy for refractory ICP (malignant MCA infarct, severe TBI)
Traumatic Brain Injury (TBI)
Severity classification (GCS)
- Mild: GCS 13–15 | Moderate: GCS 9–12 | Severe: GCS ≤ 8
ICU targets (Brain Trauma Foundation guidelines)
- ICP < 22 mmHg
- CPP 60–70 mmHg
- SBP ≥ 100 mmHg (age 50–69) or ≥ 110 mmHg (age 15–49 and >70)
- SpO2 ≥ 95%; PaO2 ≥ 60 mmHg; PaCO2 35–45 mmHg
- Temperature 36–37°C (avoid hyperthermia)
- Glucose 140–180 mg/dL
- Avoid: hypotension, hypoxia, hyponatraemia, anaemia (Hb <7)
Key interventions
- CT head within 1h of presentation
- Neurosurgery consult for significant haematoma, midline shift >5mm
- Seizure prophylaxis: levetiracetam 1000mg BD × 7 days (avoid phenytoin)
- DVT prophylaxis: mechanical from day 1; LMWH after 48–72h if haematoma stable
Acute Ischaemic Stroke
Time-critical interventions
- IV thrombolysis (tPA / tenecteplase): within 4.5h of onset; BP <185/110 before; door-to-needle <60 min
- Mechanical thrombectomy: LVO (large vessel occlusion) up to 24h from last known well; refer to intervention-capable centre
ICU management
- BP: allow permissive hypertension (up to 220/120) in ischaemic stroke NOT treated with tPA — do not lower BP in first 24h unless >220/120
- Post-tPA: keep BP <180/105 for 24h
- Glucose: treat if >180 mg/dL; avoid hypoglycaemia
- Temperature: treat fever; no evidence for induced hypothermia
- Aspirin 300mg within 24–48h (not within 24h of tPA)
- DVT prophylaxis: mechanical; LMWH from 24–48h in non-haemorrhagic strokes
Intracerebral Haemorrhage (ICH)
- Reverse anticoagulation immediately (Vitamin K 10mg IV + PCC 4-factor; dabigatran → idarucizumab; Xa inhibitor → andexanet alfa)
- BP: target SBP < 140 mmHg within 1h and maintain (INTERACT-2, ATACH-2)
- Surgical evacuation: cerebellar ICH >3cm with deterioration; lobar ICH with GCS 9–12 (consider)
- Seizure prophylaxis: only if seizures — do not give prophylactically
Status Epilepticus
Time-based algorithm
- 0–5 min: Benzodiazepine — Lorazepam 0.1mg/kg IV (or Diazepam 0.15mg/kg IV or Midazolam 0.2mg/kg IM)
- 5–20 min (if seizure continues): Levetiracetam 60mg/kg IV (max 4.5g) over 10 min — first choice; or Valproate 40mg/kg IV (avoid in liver disease, pregnancy); or Phenytoin/Fosphenytoin 20mg/kg IV
- 20–40 min (refractory SE): Repeat second-line OR try another second-line agent
- >40 min (super-refractory): Anaesthetic: Propofol, Midazolam infusion, or Thiopentone; ICU with EEG monitoring; target burst suppression
Treat underlying cause: hypoglycaemia, hyponatraemia, alcohol withdrawal, CNS infection, drug toxicity, stroke, metabolic encephalopathy.