Pharmacology of Intracranial Pressure Management

Patients presenting to the emergency department with new intracranial hemorrhage require prompt management to improve functional outcomes. These patients frequently require airway protection, however, rapid sequence intubation (RSI) can raise intracranial pressure (ICP) via direct effects of medications and reflexive responses from manipulation of the upper airway (see Pharmacology of Emergency Airway Management Capsules). Fentanyl can blunt the sympathetic response of laryngoscopy; however, use should be avoided in hypotensive or hypovolemic patients.1 The literature evaluating the effects of lidocaine on increased ICP are inconsistent and no longer recommended as pretreatment.2,3

Intracranial hemorrhage with signs of cerebral edema or hypertension should be evaluated for early hyperosmolar therapy and targeted blood pressure management, respectively. For both of these indications, several agents are available and selection is based on a variety of factors. The use of hyperosmolar agents for intracranial hypertension remains the mainstay of therapy for patients with cerebral edema. Patients with ICPs that remain elevated despite hyperosmolar therapy may be initiated on barbiturates and other sedatives. Propofol has demonstrated good outcomes for ICP control and is considered the drug of choice in these patients to allow for frequent neurologic exams. However, since propofol possesses no analgesic properties it should be combined with continuous or intermittent opioids.4

The following CAPSULE will delve into the differences between agents to treat cerebral edema, goal setting for blood pressure in the setting of intracranial hemorrhage, as well as the various antihypertensive agents used to achieve those goals.

Learning Objectives

  1. Evaluate different hyperosmolar agents for reducing intracranial pressure
  2. Select goal systolic blood pressure targets based on type of neurologic injury
  3. Design an antihypertensive regimen incorporating patient specific factors to achieve recommended blood pressure goals

Intracranial Pressure – Course Contributors

Authors Affiliation Twitter
Jamie M. Rosini, PharmD, MS, BCPS, BCCCP, DABAT Emergency Medicine Pharmacist, Christiana Care Health System @jrozzini
Ashley N. Martinelli, PharmD, BCCCP Emergency Medicine Pharmacist, University of Maryland Medical Center @RxMartinelli
Reviewers Affiliation Twitter
PharmD Reviewer: Glenn Oettinger, PharmD Thomas Jefferson University Hospital @glennoettinger
Editors Affiliation Twitter
Copy Editor: Emily Wiener, PharmD Emergency Medicine Pharmacist, Baltimore Washington Medical Center @PharmdEMily
Associate Editor: Nadia Awad, PharmD, BCPS Emergency Medicine Pharmacist, Robert Wood Johnson University Hospital @Nadia_EMPharmD
Lead Editor: Bryan Hayes, PharmD, FAACT, FASHP Clinical Pharmacy Manager, Massachusetts General Hospital @PharmERToxGuy

Splinter W, Cervenko F. Haemodynamic responses to laryngoscopy and tracheal intubation in geriatric patients: effects of fentanyl, lidocaine and thiopentone. Can J Anaesth. 1989;36(4):370-376. [PubMed]
Chraemmer-Jørgensen B, Høilund-Carlsen P, Marving J, Christensen V. Lack of effect of intravenous lidocaine on hemodynamic responses to rapid sequence induction of general anesthesia: a double-blind controlled clinical trial. Anesth Analg. 1986;65(10):1037-1041. [PubMed]
Helfman S, Gold M, DeLisser E, Herrington C. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol? Anesth Analg. 1991;72(4):482-486. [PubMed]
Kelly D, Goodale D, Williams J, et al. Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg. 1999;90(6):1042-1052. [PubMed]

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