Treatment of acute brain herniation or symptomatic intracranial hypertension (ICP >20 mmHg [27 cm H₂0]) in children*

ICP: intracranial pressure; RSI: rapid sequence intubation; IV: intravenous; PaCO₂: partial partial pressure of carbon dioxide; GCS: Glasgow coma scale; CSF: cerebrospinal fluid.
* This algorithm is intended for children in whom increased ICP is diagnosed based upon neuroimaging or intracranial monitoring, or in whom it is strongly suspected based upon signs of brain herniation. Refer to UpToDate topics on elevated ICP in children.
¶ A large diuresis is expected with mannitol and may require normal saline boluses to prevent hypotension. Thus, placement of a urinary Foley catheter is suggested. Monitoring of serum osmolal gap is necessary to avoid complications. Refer to UpToDate topics on the management of elevated ICP in children.
Δ When administering 3% saline, the expected serum sodium rise is 1 mEq/L for every 1 mL/kg bolus, and 1 mEq/L/hour for every 1 mL/kg/hour of continuous infusion. Monitoring of serum sodium is necessary to avoid complications. Patients with a serum sodium level >160 mEq/L are unlikely to benefit from hypertonic saline administration. Refer to UpToDate topics on management of elevated ICP in children.
◊ Temporary therapeutic hyperventilation (PaCO₂ 30 to 35 mmHg) may be initiated under direction by a neurosurgeon for patients with signs of impending herniation in whom surgical intervention is planned. If used, avoid hyperventilation for longer than 2 hours.
§ Monitor total dose of lidocaine administered to avoid lidocaine toxicity.
¥ Our approach to de-escalate ICP therapy is as follows: the last supportive measure added is the first one off; if tolerated, then we usually wait 24 hours before the next treatment is removed. This process is completed until all ICP management treatments are removed.