Emergency airway management in the patient with elevated ICP
- Andy Jagoda, MD
Andy Jagoda, MD
- Professor and Chair, Department of Emergency Medicine
- Mount Sinai School of Medicine
Patients with acute elevations in intracranial pressure (ICP) from trauma, stroke, infection of the central nervous system, or other processes often require emergent airway management. In managing these patients, certain medications and techniques reduce the likelihood of major fluctuations in cerebral perfusion pressure, which can exacerbate brain injury.
This topic will discuss emergent airway management in patients with elevated ICP. Other aspects of emergent airway management and diseases that cause elevations in ICP are reviewed separately.
For further discussion of emergent airway management: (see "Basic airway management in adults" and "Advanced emergency airway management in adults" and "Rapid sequence intubation for adults outside the operating room" and "Rapid sequence intubation (RSI) in children").
For discussions of injuries and diseases that elevate ICP: (see "Evaluation and management of elevated intracranial pressure in adults" and "Skull fractures in adults" and "Management of acute severe traumatic brain injury" and "Overview of the evaluation of stroke" and "Management of vasogenic edema in patients with primary and metastatic brain tumors" and "Initial approach to severe traumatic brain injury in children").
Cerebral perfusion pressure (CPP) is the driving force for blood flow to the brain. It is calculated by taking the difference between the mean arterial blood pressure (MAP) and the intracranial pressure (ICP), as expressed in the formula CPP = MAP – ICP. The pathophysiology of elevated ICP is discussed in detail separately; issues of particular relevance to airway management are highlighted below. (See "Evaluation and management of elevated intracranial pressure in adults" and "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis".)
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- RAPID SEQUENCE INTUBATION (RSI) FOR ELEVATED ICP
- PRETREATMENT AGENTS FOR RSI
- Overview and approach
- Ultra-short acting opioid
- Beta blocker
- Defasciculating dose of NMBA
- CHOICE OF INDUCTION AGENT FOR RSI
- CHOICE OF NEUROMUSCULAR BLOCKING AGENT FOR RSI
- AWAKE INTUBATION
- INITIATING MECHANICAL VENTILATION
- SUMMARY AND RECOMMENDATIONS