Podcast 871: Increased Intracranial Pressure and the Cushing Reflex

<p dir="ltr"><strong>Contributor: Travis Barlock MD</strong></p> <p dir="ltr"><strong>Education Pearls:</strong></p> <ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">The Cushing Reflex is a physiologic response to elevated intracranial pressure (ICP)</p> </li> <ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Cushing’s Triad: widened pulse pressure (systolic hypertension), bradycardia, and irregular respirations</p> </li> </ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Increased ICP results from systolic hypertension, which causes a parasympathetic reflex to drop heart rate, leading to Cushing’s Triad. </p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">The Cushing Reflex is a sign of herniation</p> </li> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Treatment includes:</p> </li> <ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Hypertonic saline is comparable to mannitol and preferable in patients with hypovolemia or hyponatremia</p> </li> <ul> <li dir="ltr" aria-level="3"> <p dir="ltr" role="presentation">Give 250-500mL of 3%NaCl</p> </li> </ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">20% Mannitol - given at a dose of 0.5-1 g/kg</p> </li> <ul> <li dir="ltr" aria-level="3"> <p dir="ltr" role="presentation">Each additional dose of 0.1 g/kg reduces ICP by 1 mm Hg</p> </li> </ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">23.4% hypertonic saline is more often given in the neuro ICU</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">8.4% Sodium bicarbonate lowers ICP for 6 hours without causing metabolic acidosis</p> </li> </ul> <li dir="ltr" aria-level="1"> <p dir="ltr" role="presentation">Non-pharmacological interventions:</p> </li> <ul> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Raise the head of the bed to 30-45 degrees</p> </li> <li dir="ltr" aria-level="2"> <p dir="ltr" role="presentation">Remove the c-collar to i