Neurocritical care after brain injury: ICP and CPP targets with the SIBICC tiered approach, mannitol and hypertonic saline, severe TBI care by BTF 4th edition, post-craniotomy care, and brain-stem death certification and apnoea testing under Indian THOTA rules with Form 10.
5 topics
- 01
ICP and CPP targets: tiered management
Recognise raised ICP, set ICP and CPP targets, and escalate through the SIBICC tiers from basic neuroprotection to decompressive craniectomy.
6 stepsAlgorithm3 dosesNew - 02
Osmotherapy: mannitol vs hypertonic saline
Choose, dose and monitor mannitol and hypertonic saline safely.
6 steps2 dosesNew - 03
Severe TBI care (BTF 4th edition)
Prevent secondary brain injury after severe TBI: airway, BP and oxygen targets, CT, seizure and VTE prophylaxis, nutrition, and neurosurgical indications.
7 stepsAlgorithm2 dosesNew - 04
Post-craniotomy care
First 24-48 h after elective or emergency craniotomy: neuro-observations, BP, seizure, sodium and complication surveillance.
7 stepsAlgorithmNew - 05
Brain-stem death testing and apnoea test (THOA rules)
Preconditions, brainstem reflex testing, apnoea test, two sets 6 hours apart by the Board of Medical Experts, Form 10, and donor management in India.
8 stepsAlgorithm1 dosesNew
Drugs in this module
Doses written for this module's context. The same drug may read differently in another module.
Mannitol 20%
Osmotic diuretic
Mannitol 20%
Osmotic diuretic
- Indications
- Raised ICP / impending herniation
- Adult dose
- 0.25-1 g/kg IV over 15-20 min (1.25-5 mL/kg of 20%); repeat 4-6 hourly as needed.
- Preparation (India)
- 20% 100 mL and 350 mL bottles (20 g/100 mL); use in-line filter, warm if crystallised.
- Renal / hepatic
- Avoid if serum osmolality > 320 mOsm/kg or osmolar gap > 20, hypovolaemia, or AKI.
- Cautions
- Osmotic diuresis → hypovolaemia and hypotension (replace urine losses); rebound ICP.
- Monitoring
- Serum Na, osmolality and osmolar gap before repeat doses; urine output; creatinine.
Hypertonic saline (3% or higher)
Osmotic agent
Hypertonic saline (3% or higher)
Osmotic agent
- Indications
- Raised ICP; herniation; hyponatraemia with neurological symptoms
- Adult dose
- 3% NaCl: 2-5 mL/kg (150-250 mL) IV over 10-20 min bolus, or infusion to target Na 145-155 mmol/L. 23.4% NaCl 30 mL over 10-20 min via central line only (herniation).
- Preparation (India)
- 3% NaCl 100 mL/500 mL bottles (available in India); 23.4% is rarely stocked. If 3% must be prepared on the unit, use only a pharmacy-approved recipe.
- Cautions
- Avoid Na rise > 10-12 mmol/L/24 h in chronic hyponatraemia; volume overload; hyperchloraemic acidosis. Peripheral 3% acceptable short-term through a good vein.
- Monitoring
- Na 4-6 hourly; stop if Na > 155-160 mmol/L.
Noradrenaline
Vasopressor
Noradrenaline
Vasopressor
- Indications
- Maintain CPP / MAP in TBI and brain-stem death donor management
- Adult dose
- 0.05-0.5 mcg/kg/min titrated to CPP 60-70 mmHg or MAP target.
- Preparation (India)
- 4 mg in 50 mL = 80 mcg/mL.
Phenytoin
Antiepileptic
Phenytoin
Antiepileptic
- Indications
- Prophylaxis of early post-traumatic seizures (BTF level IIA)
- Adult dose
- Load 15-20 mg/kg IV at ≤ 50 mg/min, then 100 mg every 8 h for 7 days.
- Preparation (India)
- 50 mg/mL; dilute only in NS (precipitates in dextrose); in-line filter.
- Cautions
- Hypotension, arrhythmia during loading (ECG monitoring), purple glove syndrome, drug interactions.
- Monitoring
- Levels (corrected for albumin).
Levetiracetam
Antiepileptic
Levetiracetam
Antiepileptic
- Indications
- Prophylaxis of early post-traumatic seizures (7 days); seizure treatment
- Adult dose
- Prophylaxis: 500-1,000 mg IV/oral every 12 h for 7 days. Status epilepticus: 60 mg/kg IV (max 4,500 mg).
- Preparation (India)
- 500 mg/5 mL vials; dilute in 100 mL NS over 15 min.
- Renal / hepatic
- Reduce maintenance if CrCl < 50 mL/min.
- Cautions
- Behavioural changes, somnolence.
Vasopressin
Vasopressor / antidiuretic
Vasopressin
Vasopressor / antidiuretic
- Indications
- Diabetes insipidus and vasoplegia in brain-stem dead organ donors
- Adult dose
- 0.5-2.4 units/h (≈ 0.01-0.04 units/min) infusion.
- Preparation (India)
- 20 units/mL ampoules; 20 units in 50 mL = 0.4 units/mL.
Module references (9)
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