CRITICAL CARE TRAUMA CENTRE
TRAUMATIC BRAIN INJURY WITH
PERSISTENT ELEVATION IN ICP
PREPRINTED ORDER
Page 1 of 2
KEY: R - REQUISITIONED
P - PROCESSED (KARDEX)
NON-MEDICATION ORDERS
R
Reason for Exam / Clinical History and Contact # required for
all Radiology / Nuclear Medicine orders.
LABORATORY WORK:
c Serum osmolality and electrolytes q 6 hours if
receiving Mannitol or Hypertonic Saline
c Blood gases q 6 hours for 48 hours then PRN
MEDICATION ORDERS
P
P
DIURECTIC:
c Mannitol (for normovolemic patient with increased ICP;
not recommended for patient with contusion)
Life-threatening Intracranial Hypertension:
c Mannitol 20% IV bolus ______ g X 1 over 20 minutes
(Recommended dose: 1 g/kg. See reverse
for calculation.)
For ICP greater than target for greater than 5 minutes
and serum osmolality is less than 320 mOsm/kg:
For patients receiving Mannitol or
Hypertonic Saline:
c Mannitol 20% IV ______ g q ______ hours PRN over
60 minutes
(Recommended dose: 0.25 - 0.5 g/kg. See reverse
for calculation.)
c Review with neurosurgery before ordering
free water
c Hypertonic Saline
(preferred over mannitol if patient has contusion)
Life-threatening Intracranial Hypertension:
Hyperventilation:
c Maintain SpO2 greater than 95% and PaCO2
between ______ ______ mmHg
c Reassess need for hyperventilation with
neurosurgery daily
c Sodium Chloride 3% IV bolus ______ mL X 1 over
20 minutes
(Recommended dose: 250 mL)
For ICP greater than target for greater than 5 minutes
and serum osmolality is less than 340 mOsm/kg and
serum sodium less than 156 mmol/L:
External Ventricular Drain Parameters
c Sodium Chloride 3% IV bolus ______ mL
q ______ hours PRN over 60 minutes
(Recommended dose: 100 mL)
c Continue with previous External Ventricular
Drainage / intraparenchymal monitor orders
OR
c Maintain continuous sedation to VAMASS 0A and
analgesia to ensure pain control.
c Revise drainage parameters as follows:
c Target ICP less than ______ mmHg
c Target CPP range ______ mmHg
(suggested 65 - 80 mmHg)
c Position drip chamber at ______ cm H2O above
external auditory meatus (use laser level)
Neuromuscular Blocking Agent:
Patient must receive continuous analgesia and sedation if
neuromuscular blocking agents are used.
c Cisatracurium
c IV bolus: ______ mg
(Recommended dose: 0.15 - 0.2 mg/kg)
c IV infusion Cisatracurium 100 mg/50 mL
______ mg/hour
(Recommended dose: 0.03 - 0.6 mg/kg/hour)
c Other: _______________________________________________
______________________________________________________
______________________________________________________
ORDER CONTINUED ON PAGE 2
DATE
PRESCRIBER’S
PRINTED NAME / SIGNATURE / CONTACT #:
PROCESSOR’S
INITIALS:
NS6365 Page 1 of 2 (2012/08/28)
(YYYY/MM/DD):
DATE
(YYYY/MM/DD):
TIME:
NURSE
INITIALS:
TIME:
DATE
(YYYY/MM/DD):
Distribution: WHITE - Chart
TIME:
CANARY - Pharmacist
PINK - Nurse
Mannitol:
Mannitol is only a temporary solution for intracranial hypertension and is associated with
rebound edema. It should only be given as a PRN bolus dose when the ICP is elevated.
Rebound edema is worse if the patient has a large contusion. Hypertonic Saline is the preferred
agent for the management of intracranial hypertension with contusion.
The usual dose for mannitol in an acute intracranial hypertensive crisis is 1 g/kg of 20% solution
X 1 over 20 minutes. Subsequent doses to maintain a desired ICP can be more conservative at
0.25 - 0.5 g/kg.
Mannitol can cause hypotension, dehydration and increase the blood viscosity, therefore, serum
osmolality should be monitored. If serum osmolality is greater than 320 mOsm/kg and ICP is still
refractory, consult neurosurgery. Hypotension reduces cerebral blood flow and should be
prevented.
To calculate the volume:
Mannitol 20% contains 100 g mannitol/500 mL of solution (0.2 g/mL)
Example: Weight: 75 kg patient
0.2 g
1 mL
=
Order:
1 g/kg
Dose:
75 g
75 g
X = 375 mL
X mL
Hypertonic Saline
Saline 3% has an osmolality that is ~ 3 times that of normal plasma. Hypertonic Saline will
increase both the osmolality and the sodium concentration. Intravascular volume is maintained
by the higher sodium concentration, reducing the potential for harmful blood pressure drops.
Serum sodium should be maintained between 145 and 155 mmol/L and serum osmolality less
than or equal to 340 mOsm/kg and serum sodium less than 156 mmol/L.
CRITICAL CARE TRAUMA CENTRE
TRAUMATIC BRAIN INJURY WITH
PERSISTENT ELEVATION IN ICP
PREPRINTED ORDER
Page 2 of 2
KEY: R - REQUISITIONED
P - PROCESSED (KARDEX)
NON-MEDICATION ORDERS
R
MEDICATION ORDERS
P
P
c Continuous CSF Drainage:
• Keep catheter open to continuous drainage.
• Turn off to drainage for 1 minute when
measuring ICP.
c If hourly drainage greater than ______ mL/hour:
c Call neurosurgery
c Raise drain to ______ cm H2O
c Close to drainage for remainder of the hour
c If no drainage X ______ hours, call neurosurgery
c Continuous ICP monitoring with Intermittent
CSF drainage:
• Keep catheter open to pressure monitoring and
closed to drainage
c Open drain X ______ minutes for up to
______ times per hour if ICP is greater than
______ mmHg to a maximum hourly CSF volume
of ______ /hour
c Open drain and remove ______ mL of CSF per
hour if ICP is greater than ______ mmHg
c If hourly drainage is less than ______ mL/hour,
call neurosurgery
c Continuous ICP Monitoring with no drainage
(by EVD or intraparenchymal monitor):
• Keep catheter open to pressure monitoring and
closed to drainage if using EVD
c Notify neurosurgery if ICP greater than
______ mmHg for greater than ______ minutes
Call neurosurgery if after troubleshooting:
• Unexplained temperature greater than 38.5°
• There is no CSF drainage and the ICP is
greater than the target pressure
• The ICP remains greater than the target pressure
despite drainage
• The waveform becomes dampened
ORDER INITIATED ON PAGE 1
DATE
PRESCRIBER’S
PRINTED NAME / SIGNATURE / CONTACT #:
PROCESSOR’S
INITIALS:
NS6365 Page 2 of 2 (2012/10/22)
(YYYY/MM/DD):
DATE
(YYYY/MM/DD):
TIME:
NURSE
INITIALS:
TIME:
DATE
(YYYY/MM/DD):
Distribution: WHITE - Chart
TIME:
CANARY - Pharmacist
PINK - Nurse