Management

1. Bed rest, 20-308 head-up tilt, sedation, quiet environment, minimal suction and noise. Sedation is often necessary to overcome a hyperadrenergic state but sedative-induced hypotension should be avoided. The tape tethering the endotracheal tube in place should not occlude jugular venous drainage.

2. Ventilate if GCS <8, airway unprotected or excessively agitated.

3. Maintain PaCO2 at 4-4.5 kPa and avoid rapid rises. CSF bicarbonate levels re-equilibrate within 4-6 h, negating any benefit from hyperventilation.

4. If possible, monitor ICP. Aim to maintain ICP <20 mmHg and cerebral perfusion pressure (CPP=MAP-ICP) >70 mmHg. Vasopressors may be needed. Do not treat systemic hypertension unless very high (e.g. systolic >220-230 mmHg).

5. Jugular bulb venous saturation (SjO2) and lactate may be useful monitoring techniques though do not detect regional ischaemia.

6. Give mannitol 0.5 mg/kg over 15 min. Repeat 4-hrly depending on CPP measurements and/or clinical signs of deterioration. Stop when plasma osmolality reaches 310-320 mOsmol/kg.

7. Avoid severe alkalosis as cerebral vascular resistance rises and cerebral ischaemia increases.

8. Consider specific treatment, e.g. for meningo-encephalitis, malaria, hepatic encephalopathy, surgery. Some neurosurgeons decompress the cranium for generalised oedema by removing a skull flap. Seek local advice. Dexamethasone 4-16 mg qds IV is beneficial for oedema surrounding a tumour or abscess and for herpes simplex encephalitis.

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