Elevated intracranial pressure (ICP) in children: Management
- Robert C Tasker, MBBS, MD
Robert C Tasker, MBBS, MD
- Professor of Neurology and Anaesthesia (Pediatrics)
- Harvard Medical School
- Section Editors
- Susan B Torrey, MD
Susan B Torrey, MD
- Section Editor — Pediatric Resuscitation; Pediatric Trauma
- Associate Professor of Pediatrics
- Baylor College of Medicine
- Pediatric Emergency Medicine
- Texas Children’s Hospital
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
- Marc C Patterson, MD, FRACP
Marc C Patterson, MD, FRACP
- Section Editor — Pediatric Neurology
- Professor of Neurology, Pediatrics, and Medical Genetics
- Chair, Division of Child and Adolescent Neurology
- Mayo Clinic College of Medicine
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
The management of elevated ICP in children will be reviewed here.
The clinical manifestations and diagnosis of elevated intracranial pressure in children and the initial approach to severe traumatic brain injury in children is discussed separately. (See "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis" and "Severe traumatic brain injury in children: Initial evaluation and management".)
Although discussed separately, the assessment and management of elevated ICP are performed jointly in practice. Acutely elevated ICP should be suspected in children with any one of the following findings (see "Elevated intracranial pressure (ICP) in children: Clinical manifestations and diagnosis", section on 'Acutely elevated ICP'):
●Severe headache with vomiting
- Stevens RD, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2015; 23 Suppl 2:S76.
- Seder DB, Jagoda A, Riggs B. Emergency Neurological Life Support: Airway, Ventilation, and Sedation. Neurocrit Care 2015; 23 Suppl 2:S5.
- Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med 2012; 13 Suppl 1:S1.
- Tasker RC, Adelson PD. Head and Spinal Cord Trauma. In: Rogers’ Textbook of Pediatric Intensive Care, 5th ed, Nichols DG, Shaffner DH (Eds), Lippincott Williams & Wilkins, Philadelphia 2015. p.951.
- Crompton EM, Lubomirova I, Cotlarciuc I, et al. Meta-Analysis of Therapeutic Hypothermia for Traumatic Brain Injury in Adult and Pediatric Patients. Crit Care Med 2017; 45:575.
- Tasker RC, Vonberg FW, Ulano ED, Akhondi-Asl A. Updating Evidence for Using Hypothermia in Pediatric Severe Traumatic Brain Injury: Conventional and Bayesian Meta-Analytic Perspectives. Pediatr Crit Care Med 2017; 18:355.
- Feldman Z, Kanter MJ, Robertson CS, et al. Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg 1992; 76:207.
- Agbeko RS, Pearson S, Peters MJ, et al. Intracranial pressure and cerebral perfusion pressure responses to head elevation changes in pediatric traumatic brain injury. Pediatr Crit Care Med 2012; 13:e39.
- Meixensberger J, Baunach S, Amschler J, et al. Influence of body position on tissue-pO2, cerebral perfusion pressure and intracranial pressure in patients with acute brain injury. Neurol Res 1997; 19:249.
- Shah AK, Fuerst D, Sood S, et al. Seizures lead to elevation of intracranial pressure in children undergoing invasive EEG monitoring. Epilepsia 2007; 48:1097.
- Kneen R, Michael BD, Menson E, et al. Management of suspected viral encephalitis in children - Association of British Neurologists and British Paediatric Allergy, Immunology and Infection Group national guidelines. J Infect 2012; 64:449.
- Allen BB, Chiu YL, Gerber LM, et al. Age-specific cerebral perfusion pressure thresholds and survival in children and adolescents with severe traumatic brain injury*. Pediatr Crit Care Med 2014; 15:62.
- Tasker RC, Acerini CL. Cerebral edema in children with diabetic ketoacidosis: vasogenic rather than cellular? Pediatr Diabetes 2014; 15:261.
- Brophy GM, Human T, Shutter L. Emergency Neurological Life Support: Pharmacotherapy. Neurocrit Care 2015; 23 Suppl 2:S48.
- Härtl R, Bardt TF, Kiening KL, et al. Mannitol decreases ICP but does not improve brain-tissue pO2 in severely head-injured patients with intracranial hypertension. Acta Neurochir Suppl 1997; 70:40.
- Bell BA, Smith MA, Kean DM, et al. Brain water measured by magnetic resonance imaging. Correlation with direct estimation and changes after mannitol and dexamethasone. Lancet 1987; 1:66.
- Millson C, James HE, Shapiro HM, Laurin R. Intracranial hypertension and brain oedema in albino rabbits. Part 2: Effects of acute therapy with diuretics. Acta Neurochir (Wien) 1981; 56:167.
- Nath F, Galbraith S. The effect of mannitol on cerebral white matter water content. J Neurosurg 1986; 65:41.
- Paczynski RP. Osmotherapy. Basic concepts and controversies. Crit Care Clin 1997; 13:105.
- White H, Cook D, Venkatesh B. The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury. Anesth Analg 2006; 102:1836.
- Gantner D, Moore EM, Cooper DJ. Intravenous fluids in traumatic brain injury: what's the solution? Curr Opin Crit Care 2014; 20:385.
- Khanna S, Davis D, Peterson B, et al. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury. Crit Care Med 2000; 28:1144.
- Shein SL, Ferguson NM, Kochanek PM, et al. Effectiveness of Pharmacological Therapies for Intracranial Hypertension in Children With Severe Traumatic Brain Injury--Results From an Automated Data Collection System Time-Synched to Drug Administration. Pediatr Crit Care Med 2016; 17:236.
- Fisher B, Thomas D, Peterson B. Hypertonic saline lowers raised intracranial pressure in children after head trauma. J Neurosurg Anesthesiol 1992; 4:4.
- Friess SH, Helfaer MA, Raghupathi R, Huh JW. An evidence-based approach to severe traumatic brain injury in children. Pediatric Emergency Medicine Practice 2007; 4(12):1.
- Skippen P, Seear M, Poskitt K, et al. Effect of hyperventilation on regional cerebral blood flow in head-injured children. Crit Care Med 1997; 25:1402.
- Cormio M, Gopinath SP, Valadka A, Robertson CS. Cerebral hemodynamic effects of pentobarbital coma in head-injured patients. J Neurotrauma 1999; 16:927.
- Pittman T, Bucholz R, Williams D. Efficacy of barbiturates in the treatment of resistant intracranial hypertension in severely head-injured children. Pediatr Neurosci 1989; 15:13.
- Ward JD, Becker DP, Miller JD, et al. Failure of prophylactic barbiturate coma in the treatment of severe head injury. J Neurosurg 1985; 62:383.
- Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011; 364:1493.
- Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med 2016; 375:1119.
- THRESHOLD FOR TREATMENT
- INITIAL STABILIZATION
- Temperature control
- Neurosurgical consultation
- TREATMENT OF ELEVATED ICP
- General measures for all patients
- Measures in intubated patients
- Medical treatment of sustained intracranial hypertension or impending herniation
- - Hyperosmolar therapy
- Hypertonic saline
- - Therapeutic hyperventilation
- Refractory intracranial hypertension
- Patients with vasogenic edema
- Contraindicated therapies
- ONGOING MANAGEMENT
- SUMMARY AND RECOMMENDATIONS