Trauma Resuscitation — Treat Brain Injury — Clinical Pathway: Emergency

Trauma Resuscitation Clinical Pathway — Emergency Department

Treat Brain Injury

Goal

Recognize and treat suspected intracranial pressure (ICP).

Assessment Intervention(s)
Neurologic
  • Signs of elevated ICP in the absence of an ICP monitor include a focal neurologic deficit and/or Cushing's triad (hypertension, bradycardia & abnormal breathing)
    • Focal neurological exam deficit (e.g. unilateral dilated pupil)
AND/OR
  • Cushing’s triad: Hypertension, bradycardia, abnormal breathing
  • Consider the following interventions if concern for elevated ICP:
    • Hyperventilate to transiently lower EtCO2 to 30-34 mmHg:
      • Monitor vital signs and/or abnormal portion of exam (e.g. pupil dilation) for signs of improvement.
      • Reassess the need for hyperventilation to avoid prolonged duration to avoid cerebral ischemia.
    • Hyperosmolar therapy:
      • Hypertonic 3% saline bolus (5 mL/kg IV bolus); may repeat PRN
    • Secondary sedation post-RSI:
      • Consider fentanyl, ketamine and/or midazolam based on the patient’s clinical status.
      • Administer the minimal amount needed to avoid hypotension.
    • If seizure symptoms present, consider anti-epileptic medications
    • Status Epilepticus Clinical Pathway, ED
Circulation
  • Maintain euvolemia
  • AVOID hypotension

Policy

Administration of Hypertonic (3%) Saline

Job Aid

Guidelines for Use of Hypertonic Saline in the PICU