Traumatic brain injury with raised ICP — FFICM MCQ

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HardNeuro-ICUTraumatic brain injury with raised ICPFFICM

A 24-year-old man with severe traumatic brain injury is ventilated on ICU. ICP rises to 28 mmHg for 20 minutes despite sedation, analgesia, head-up positioning and normocapnia. CT shows diffuse swelling without a surgically evacuable mass. Sodium is 139 mmol/L and MAP is 88 mmHg. What is the most appropriate management?

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Correct answer: A — Give hypertonic saline and reassess cerebral perfusion pressure

Option A, give hypertonic saline and reassess cerebral perfusion pressure, is correct because sustained ICP above 22 mmHg for more than 5 to 10 minutes despite optimised first-tier measures (sedation, analgesia, head-up tilt, normocapnia) defines refractory intracranial hypertension requiring second-tier osmotherapy. Hypertonic saline draws free water out of the injured brain across an intact blood-brain barrier, reducing intracranial volume while supporting intravascular volume and MAP, which protects cerebral perfusion pressure (CPP = MAP minus ICP). With sodium at 139 mmol/L there is ample room to raise osmolality safely before approaching the usual 155 to 160 mmol/L ceiling. This is standard tiered ICP management in severe traumatic brain injury with diffuse swelling and no surgical target on CT. Why the other options are wrong: E. Hyperventilate to PaCO2 2.5 kPa for several hours: aggressive hypocapnia causes cerebral vasoconstriction that can precipitate ischaemia if sustained, so it is reserved as a brief bridging measure for acute deterioration, not a several-hour strategy. B. Lower MAP to reduce cerebral blood volume: dropping MAP directly reduces CPP (CPP = MAP minus ICP) and risks secondary ischaemic injury; blood pressure should be maintained, not lowered, in this context. C. Give hypotonic fluid to reduce sodium: hypotonic fluid lowers plasma osmolality, promoting cerebral oedema and worsening ICP, the opposite of the required effect. D. Stop sedation to assess neurology: withdrawing sedation in uncontrolled intracranial hypertension risks coughing, straining and further ICP surges, and neurological assessment is not the priority when ICP is already dangerously elevated. Key point: Refractory ICP elevation despite optimised first-tier measures mandates second-tier osmotherapy (hypertonic saline) while actively protecting cerebral perfusion pressure, not manoeuvres that lower MAP or induce prolonged hypocapnia.

Reference: NHS Greater Glasgow and Clyde / Right Decisions Scotland, Traumatic Brain Injury guideline: hypertonic saline as first-line tier-2 osmotherapy for ICP control, https://www.rightdecisions.scot.nhs.uk/media/beinuo2v/traumatic-brain-inj-guideline-895.pdf