Emergency Neurological Life Support: Intracranial Hypertension and Herniation

Abstract

Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this Emergency Neurological Life Support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.

Bedside external ventricular drain placement for haemorrhagic stroke patients with brain herniation and acute hydrocephalus: A case series

“…The concept of a “brain code”, where a protocol‐driven approach for the aggressive medical management of brain herniation, akin to advanced cardiac life support, is being implemented in certain centres in North America . Should a coordinated effort be adopted in our locality, our experience suggests that bedside EVD is a feasible procedure which could be considered in carefully‐selected patients as part of a stepwise management algorithm .…”

“…The concept of a “brain code”, where a protocol‐driven approach for the aggressive medical management of brain herniation, akin to advanced cardiac life support, is being implemented in certain centres in North America . Should a coordinated effort be adopted in our locality, our experience suggests that bedside EVD is a feasible procedure which could be considered in carefully‐selected patients as part of a stepwise management algorithm . According to international multidisciplinary practice guidelines for traumatic brain injury, ICP monitoring is indicated for comatose patients (GCS 3–8) that have either an abnormal CT scan or meet at least two of the following criteria: (i) age >40 years; (ii) systolic blood pressure <90 mmHg; or (iii) abnormal posturing .…”

“…According to international multidisciplinary practice guidelines for traumatic brain injury, ICP monitoring is indicated for comatose patients (GCS 3–8) that have either an abnormal CT scan or meet at least two of the following criteria: (i) age >40 years; (ii) systolic blood pressure <90 mmHg; or (iii) abnormal posturing . Indications for haemorrhagic stroke are not well established, but similar criteria have been utilized in nontraumatic “emergency neurological life support” protocols that similarly recommend EVD placement as a first‐tier intervention …”

Associação de hipernatremia com o prognóstico e a mortalidade de pacientes com traumatismo cranioencefálico grave em um hospital terciário brasileiro

“…(4,10,40,63) Além de permitir o diagnóstico precoce dos quadros de HIC, o monitoramento da PIC também possibilita o cálculo da PPC, otimizando ainda mais a terapêutica. (4,33,98) Por ser o monitoramento da PIC uma prática rotineira adotada em praticamente todos os serviços de neurotrauma dos países economicamente favorecidos, não há nestes centros estudos prospectivos controlados comparativos entre o uso ou não da monitorização da PIC, apenas pesquisas retrospectivas e observacionais (que demonstraram piores desfechos em pacientes não monitorizados), o que limita as evidências atuais. (10,63) O único estudo prospectivo randomizado sobre o tema foi realizado na América do Sul e não demonstrou diferenças entre o tratamento guiado pela monitorização contínua e o tratamento guiado pelo reexame clínico seriado e as imagens tomográficas no desfecho funcional em seis meses.…”

“…(63,99) Pacientes com TCE grave e lesões intracranianas visíveis na tomografia de crânio de admissão possuem risco estimado superior a 50% de desenvolver hipertensão intracraniana, por isso, neste grupo de pacientes, é recomendação nível IIB pelas diretrizes do BTF o implante do cateter de monitorização contínua da PIC. (4,10,40,47,98) O risco de HIC também é aumentado em pacientes com TCE grave e tomografia de admissão normal, mas com dois dos três critérios:…”