|
• 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)
|
