Which of the following drugs would be used to treat a child who has increased ICP resulting from cerebral edema?

If intracranial pressure (ICP) is increased, clinicians should monitor intracranial and cerebral perfusion pressure, and pressures should be controlled. The goal is to maintain ICP at ≤ 20 mm Hg and cerebral perfusion pressure at 50 to 70 mm Hg. ICP is usually lower in children than in adults. In neonates, ICP can be below the atmospheric pressure. Thus, children are evaluated independently from adult guidelines.

Control of increased ICP involves several strategies:

Sedation: Sedatives may be necessary to control agitation, excessive muscular activity (eg, due to delirium), or pain, which can increase ICP. Propofol is often used in adults (contraindicated in children) because onset and duration of action are quick; dose is 0.3 mg/kg/hour by continuous IV infusion, titrated gradually up to 3 mg/kg/hour as needed. An initial bolus is not used. The most common adverse effect is hypotension. Prolonged use at high doses can cause pancreatitis. Benzodiazepines (eg, midazolam, lorazepam) can also be used. Because sedatives can mask neurologic findings and changes, their use should be minimized and, whenever possible, avoided. Antipsychotics should be avoided if possible because they can delay recovery. Sedatives are not used to treat agitation and delirium due to hypoxia; oxygen is used instead.
Hydration: Isotonic fluids are used. Providing free water through IV fluids (eg, 5% dextrose, 0.45% saline) can aggravate cerebral edema and should be avoided. Fluids may be restricted to some degree, but patients should be kept euvolemic. If patients have no signs of dehydration or fluid overload, IV fluids with normal saline can be started at 50 to 75 mL/hour. The rate can be increased or decreased based on serum sodium, osmolality, urine output, and signs of fluid retention (eg, edema).
Diuretics: Serum osmolality should be kept at 295 to 320 mOsm/kg. Osmotic diuretics (eg, mannitol) may be given IV to lower ICP and maintain serum osmolality. These drugs do not cross the blood-brain barrier. They pull water from brain tissue across an osmotic gradient into plasma, eventually leading to equilibrium. Effectiveness of these drugs decreases after a few hours. Thus, they should be reserved for patients whose condition is deteriorating (eg, those with acute brain herniation) or used preoperatively for patients with hematomas. Mannitol 20% solution is given 0.5 to 1 g/kg IV (2.5 to 5 mL/kg) over 15 to 30 minutes, then given as often as needed (usually every 6 to 8 hours) in a dose ranging from 0.25 to 0.5 g/kg (1.25 to 2.5 mL/kg). Mannitol must be used cautiously in patients with severe coronary artery disease, heart failure, renal insufficiency, or pulmonary vascular congestion because mannitol rapidly expands intravascular volume. Because osmotic diuretics increase renal excretion of water relative to sodium, prolonged use of mannitol may result in water depletion and hypernatremia. Furosemide 1 mg/kg IV can decrease total body water, particularly when transient hypervolemia associated with mannitol is to be avoided. Fluid and electrolyte balance should be monitored closely while osmotic diuretics are used. A 3% saline solution is another potential osmotic agent to control ICP.
Blood pressure (BP) control: Systemic antihypertensives are needed only when hypertension is severe (> 180/95 mm Hg). How much BP is reduced depends on the clinical context. Systemic BP needs to be high enough to maintain cerebral perfusion pressure even when ICP increases. Hypertension can be managed by titrating a nicardipine drip (5 mg/hour, increased by 2.5 mg every 5 minutes to a maximum of 15 mg/hour) or by boluses of labetalol (10 mg IV over 1 to 2 minutes, repeated every 10 minutes to a maximum of 150 mg).
Corticosteroids: Corticosteroids are useful for treating vasogenic brain edema. Vasogenic edema results from disruption of the blood-brain barrier, which may occur in patients with a brain tumor. Cytotoxic edema results from cell death and breakdown, which may occur in patients with stroke, cerebral hemorrhage, or trauma; it may also occur after hypoxic brain damage due to cardiac arrest. Treatment with corticosteroids is effective only for tumors and sometimes abscesses of the brain when vasogenic edema is present. Corticosteroids are ineffective for cytotoxic edema and can increase plasma glucose, exacerbating cerebral ischemia and complicating management of diabetes mellitus. For patients without brain ischemia, an initial dose of dexamethasone 20 to 100 mg, followed by 4 mg once a day appears to be effective while minimizing adverse effects. Dexamethasone can be given IV or orally.
Removal of cerebrospinal fluid (CSF): CSF can be slowly removed through a shunt inserted into the ventricles to help lower increased ICP. CSF is removed at a rate of 1 to 2 mL/minute for 2 to 3 minutes. Continuous drainage of CSF (eg, through a lumbar drain) should be avoided because it may lead to brain herniation.
Position: Positioning the patient to maximize venous outflow from the head can help minimize increases in ICP. The head of the bed can be elevated to 30° (with the head above the heart) as long as cerebral perfusion pressure remains at the desired range. The patient’s head should be kept in a midline position, and neck rotation and flexion should be minimized. Tracheal suctioning, which can increase ICP, should be limited.

If ICP continues to increase despite other measures to control it, the following may be used:

Pentobarbital coma: Pentobarbital can reduce cerebral blood flow and metabolic demands. However, its use is controversial because the effect on clinical outcome is not consistently beneficial, and treatment with pentobarbital can lead to complications (eg, hypotension). In some patients with refractory intracranial hypertension that does not respond to standard hyperventilation and hyperosmolar therapy, pentobarbital can improve functional outcome. Coma is induced by giving pentobarbital 10 mg/kg IV over 30 minutes, followed by 5 mg/kg/hour for 3 hours, then 1 mg/kg/hour. The dose may be adjusted to suppress bursts of EEG activity, which is continuously monitored. Hypotension is common and is managed by giving fluids and, if necessary, vasopressors. Other possible adverse effects include arrhythmias, myocardial depression, and impaired uptake or release of potentially neurotoxic glutamate in the brain.

Medically Reviewed by Christopher Melinosky, MD on September 14, 2020

If you bump your knee, it's likely to swell. But what if you injure your brain?

Swelling -- also called edema -- is the body's response to many types of injury. It can result from overuse or infection. Usually, swelling happens quickly and is simple to treat with some combination of rest, ice, elevation, medication, or removal of excess fluid.

Your brain can also swell as a result of injury, illness, or other reasons. Brain swelling, though, can quickly cause serious problems -- including death. It's also usually more difficult to treat. As your body's master control system, the brain is critical to overall function. Yet, the thick, bony skull that snugly protects this vital organ provides little room for the brain to swell.

Brain swelling goes by many names:

Brain edema
Elevated intracranial pressure
Cerebral edema

Swelling can occur in specific locations or throughout the brain. It depends on the cause. Wherever it occurs, brain swelling increases pressure inside the skull. That's known as intracranial pressure, or ICP. This pressure can prevent blood from flowing to your brain, which deprives it of the oxygen it needs to function. Swelling can also block other fluids from leaving your brain, making the swelling even worse. Damage or death of brain cells may result.

Injury, other health problems, infections, tumors, and even high altitudes -- any of these problems can cause brain swelling to occur. The following list explains different ways the brain can swell:

Traumatic brain injury (TBI): A TBI is also called a head injury, brain injury, or acquired brain injury. In TBI, a sudden event damages the brain. Both the physical contact itself and the quick acceleration and deceleration of the head can cause the injury. The most common causes of TBI include falls, vehicle crashes, being hit with or crashing into an object, and assaults. The initial injury can cause brain tissue to swell. In addition, broken pieces of bone can rupture blood vessels in any part of the head. The body's response to the injury may also increase swelling. Too much swelling may prevent fluids from leaving the brain.
Ischemic strokes: Ischemic stroke is the most common type of stroke and is caused by a blood clot or blockage in or near the brain. The brain is unable to receive the blood -- and oxygen -- it needs to function. As a result, brain cells start to die. As the brain responds, swelling occurs.
Hemorrhagic strokes: Hemorrhage refers to blood leaking from a blood vessel in the brain (intracerebral). Hemorrhagic strokes are the most common type of stroke. They occur when blood vessels anywhere in the brain rupture. As blood leaks and the body responds, pressure builds inside the brain. High blood pressure is thought to be the most frequent cause of this kind of stroke. Hemorrhages in the brain can also be due to head injury, certain medications, and unknown malformations present from birth.
Infections: Illness caused by an infectious organism such as a virus or bacterium can lead to brain swelling. Examples of these illnesses include:
- Meningitis: This is an infection in which the covering of the brain becomes inflamed. It can be caused by bacteria, viruses, other organisms, and some medications.
- Encephalitis: This is an infection in which the brain itself becomes inflamed. It is most often caused by a group of viruses and is spread usually through insect bites.
- Toxoplasmosis: This infection is caused by a parasite. Toxoplasmosis most often affects fetuses, young infants, and people with damaged immune systems.
- Subdural abscess: Subdural abscess (empyema) refers to an area of the brain becoming abscessed or filled with pus, usually after another illness such as meningitis or a sinus infection. The infection can spread quickly, causing swelling and blocking other fluid from leaving the brain.
Tumors: Growths in the brain can cause swelling in several ways. As a tumor develops, it can press against other areas of the brain. Tumors in some parts of the brain may block cerebrospinal fluid from flowing out of the brain. New blood vessels growing in and near the tumor can leak and also lead to swelling.
High altitudes: Although researchers don't know the exact causes, brain swelling is more likely to occur at altitudes above 4,900 feet. This type of brain edema is usually associated with severe acute mountain sickness (AMS) or high-altitude cerebral edema (HACE).

Symptoms of brain swelling vary, depending on the severity and the cause. Usually they begin suddenly. You may notice any of these symptoms:

The steps used by your doctor to diagnose brain swelling depend on the symptoms and the suspected cause. Common exams and tests used in the diagnosis include:

Head and neck exam
Neurologic exam
CT scan of the head to identify the extent and location of the swelling
MRI of the head to identify the extent and location of the swelling
Blood tests to check for causes of the swelling
Lumbar puncture

Minor cases of brain swelling due to causes such as moderate altitude sickness or a slight concussion often resolve within a few days. In most cases, however, more treatment is needed quickly.

The goal is to assure that the brain receives enough blood and oxygen to remain healthy while the swelling is relieved and any underlying causes are treated. This may require a combination of medical and surgical treatments. Prompt treatment usually results in quicker and more complete recovery. Without it, some damage may remain.

Supportive care for brain edema may include any combination of the following:

Hyperbaric oxygen therapy: Providing oxygen through a respirator or in a chamber helps make sure that the blood has enough oxygen in it.
IV fluids: Giving fluids and medicine through an IV can keep blood pressure from dropping too low. This helps to make sure that the body -- including the brain -- is receiving enough blood. However, some fluids can make swelling worse. Doctors attempt to use the right amounts of the right fluids in someone with brain swelling.
Lowering body temperature (hypothermia): Lowering the temperature of the body and brain helps relieve swelling and allows the brain to heal. Hypothermia as a treatment for brain swelling is not widely used, however.
Medication: In some cases of brain edema, your doctor may start a drug to help relieve the swelling. Medication may also be given for other reasons, such as to slow your body's response to the swelling or to dissolve any clots. The drugs your doctor gives you depend on the cause and symptoms of brain swelling.
Ventriculostomy: In this procedure, a surgeon cuts a small hole in the skull and inserts a plastic drain tube. Cerebrospinal fluid is drained from inside the brain, helping to relieve the pressure.
Surgery: Surgery may have one or more of these goals:
- Removing part of the skull to relieve intracranial pressure; this procedure is called decompressive craniectomy.
- Removing or repairing the source of the swelling, such as repairing a damaged artery or vein or removing a growth

It's common to have lingering effects from brain swelling. The problems you notice depend on the severity as well as the location of the injury. Symptoms may be noticed with any of the following:

Sleeping
Thinking and attention skills
Headaches
Depression
Communication skills
Movement

Your health care team is available to help you deal with these challenges. While some problems may continue to diminish over time, others may require ongoing treatment.

To protect the brain, keep these tips in mind as you go about your daily activities:

Use a helmet when biking, skating, playing contact sports, or performing other activities in which you might fall and hit your head.
Wear seat belts properly when driving or riding in vehicles.
Make sure you are doing all you can to control high blood pressure and heart disease.
Avoid smoking.
When traveling to high elevations, take your time -- allow your body to adjust to the altitude.