TBI & ICP Management

• Treat ICP above 22 mm Hg; escalate care stepwise: head-up 30° and normocapnia (35–38) plus sedation → hypertonic saline/mannitol → EVD → paralysis → pentobarbital/decompressive craniectomy.
• CPP 60–70 mmHg; avoid hypotension (SBP ≥100) and hypoxia, since single episodes worsen outcomes.
• In severe TBI give levetiracetam seizure prophylaxis ×7 d; steroids are not used routinely.
• Pupil asymmetry or herniation calls for hyperosmolar therapy plus brief hyperventilation only as a bridge to definitive action.

Managing Elevated Intracranial Pressure

• Immediate steps for elevated ICP: head of bed >30° · neck straight, avoid jugular compression · keep normocapnia · sedation (propofol preferred for ICP control; benzodiazepines acceptable alternatives) · mannitol bolus 0.75–1.5 g/kg or 23.4% saline 30–60 mL via central line · for acute deterioration, consider hyperventilation (pCO₂ 25–30) for 30 min
• ICP still above 22 mm Hg?
• Extended measures for refractory ICP elevation: osmotic therapy with mannitol or hypertonic saline targeting Na 145–160 · CSF drainage via ventriculostomy if not done · decompressive craniectomy (RESCUEicp, for refractory elevation >25 mm Hg) · prophylactic hypothermia is NOT recommended
• Consider head CT — look for a lesion needing immediate surgery · check coagulation status (correct coagulopathy, especially with new bleeding on CT)