Table 3 Neuroprotective strategy in ICU
• Head neutral | |
• Head up | |
• No compression on internal jugular veins | |
• Maintain normal intrathoracic pressure, avoid airway obstruction, brochospasm, straining, coughing | |
• Premedication before intubation with | |
 ◦ Fentanyl 2 mcg/kg (caution for bradypnea, bradycardia and respiratory arrest) | |
• Rapid sequence induction with ketamine and midazolam or ketamine and propofol or etomidate | |
• Muscle relaxant | |
 ◦ Rocuronium preferable | |
 ◦ Succinylcholine (fasciculations can cause increase in ICP; hyperkalemia in patients with extrajunctional receptors) | |
• Hemodynamic and metabolic targets | |
 ➢Mean arterial pressure MAPs 90 to 100 mmHg (titrate according to baseline MAP± 20%) | |
 ➢PaO2 80 to 100 mmHg | |
 ➢PaCO2 30 to 35 mmHg | |
 ➢pH 7.35 to 7.45 | |
 ➢Normoglycemia | |
 ➢Normothermia | |
 ➢Adequate sedation/analgesia | |
• Potential cerebrovasodilators should not be used | |
 ➢Vasopressin | |
 ➢Calcium channel blockers | |
 ➢NTG | |
 ➢Nitroprusside | |
• For acute rise in intracranial pressure | |
 ➢Hyper ventilate to achieve PaCO2 25 to 30 mmHg | |
 ➢Hypertonic saline OR mannitol bolus | |
 ➢Deepen sedation (boluses of midazolam) |