›Hold if serum osmolality > 320 mOsm/kg
›Contraindication
›Hypovolemia or hypotension
›Renal failure relative contraindication
›Hypertonic saline
›3% NaCl for herniation when mannitol contraindicated
›250 mL IV bolus over 15-20 minutes
›Preferred in hypotensive or volume-depleted patients
›23.4% NaCl for acute herniation
›30 mL IV bolus via central line
›Rapid ICP reduction effect
›Serum sodium monitoring
›Target serum sodium 145-155 mmol/l in ICP management
›Do not exceed 160 mmol/l
›Warfarin reversal
›4-factor prothrombin complex concentrate
›Preferred over FFP for speed and volume
›Dose based on INR and weight per local protocol
›INR < 2.0: 25 units/kg
›INR 2.0-4.0: 35 units/kg
›INR > 4.0: 50 units/kg
›Vitamin K IV concurrent
›10 mg IV over 30-60 minutes
›Prevents INR rebound
›Target INR < 1.5 before surgery
›Direct oral anticoagulant reversal
›Dabigatran: idarucizumab
›5 g IV as two 2.5 g boluses
›Class I reversal agent for dabigatran
›Factor Xa inhibitors (rivaroxaban, apixaban)
›Andexanet alfa: preferred specific reversal
›Low dose: 400 mg IV bolus then 480 mg over 2 hours
›High dose: 800 mg IV bolus then 960 mg over 2 hours
›4-factor PCC 50 units/kg IV as alternative if andexanet unavailable
›Heparin reversal
›Protamine sulfate 1 mg per 100 units heparin given in preceding 2-3 hours
›Maximum 50 mg IV slowly over 10 minutes
›Platelet transfusion
›Target platelet count > 100 x 10^9/L preoperatively
›Antiplatelet agent use: transfuse 1 adult dose regardless of count
›Seizure prophylaxis
›Levetiracetam
›1000-2000 mg IV loading dose
›Maintenance 500-1000 mg IV or PO every 12 hours
›Preferred agent: no drug interactions, renal dosing required
›Phenytoin alternative
›15-20 mg/kg IV loading at maximum 50 mg/min
›Monitor for hypotension and arrhythmia during infusion
›Duration: 7 days post-trauma is standard
›Based on Brain Trauma Foundation guideline
›Extended if post-traumatic seizures occur
›Active seizure treatment
›Lorazepam 0.1 mg/kg IV for status epilepticus
›Maximum 4 mg per dose
›Repeat in 5 minutes if seizure continues
›Lacosamide IV alternative if benzodiazepine insufficient
›Craniotomy principles
›Preferred over burr hole drainage for temporal EDH
›More complete evacuation
›Allows identification and coagulation of bleeding vessel
›Middle meningeal artery embolization
›Emerging adjunct or alternative in selected cases
›Not standard first-line treatment for acute EDH
›Timing
›Every hour of delay in comatose patient increases mortality
›Target time to OR < 4 hours from diagnosis in herniation
ICP management post-operatively
›General measures
›Head of bed 30 degrees
›Euvolemia maintenance
›Normothermia target
›Temperature > 37.5 C worsens secondary injury
›Normoglycemia
›Glucose 6-10 mmol/l target
›Sedation and analgesia
›Propofol infusion for ventilated patients
›5-50 mcg/kg/min titrated to ICP and neurological goals
›Propofol infusion syndrome monitor with prolonged high-dose use
›Fentanyl for analgesia
›0.5-2 mcg/kg/hour IV infusion
›Minimizes ICP surges with care
›Refractory ICP escalation
›Barbiturate coma if ICP unresponsive to measures
›Pentobarbital 10 mg/kg IV over 30 min loading dose
›Maintenance 1-3 mg/kg/hour
›EEG burst suppression monitoring required