Second-Tier ICP Management TBI — FRCA Final MCQ

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ModerateNeuroanaesthesiaSecond-Tier ICP Management TBIFRCA Final

A 50-year-old man on ICU with traumatic brain injury has an ICP monitor in situ. Current medications include: propofol 4 mg/kg/hr, fentanyl 2 mcg/kg/hr, and mannitol PRN. The ICP is 22 mmHg. The team wishes to add a second-tier agent for ICP control. According to BTF guidelines, which agent can be added?

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Correct answer: B — Hypertonic saline (as an alternative/addition to mannitol)

Second-tier ICP management (after optimising first-tier measures: sedation, analgesia, head elevation, normocapnia, normothermia, osmotic therapy) includes: hypertonic saline (if not already used – can be used alongside or as alternative to mannitol), moderate hyperventilation (PaCO2 4.0-4.5 kPa for short periods), CSF drainage, and muscle paralysis. Third-tier options include: barbiturate coma, decompressive craniectomy, and therapeutic hypothermia (limited evidence). Dexamethasone is NOT recommended for TBI-related cerebral oedema (CRASH trial showed harm). Nimodipine is for SAH vasospasm, not TBI.

Reference: Brain Trauma Foundation – 2016 – TBI guidelines; Edwards P et al – 2005 – CRASH trial