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Critical Care Medicine

Answer 4
  1. Therapeutic hyperthermia (core temperature > 38.5°C). Experimental and initial clinical data suggest that moderate hypothermia (33°C) for 24 hours after severe head injury may improve outcome,6 but therapeutic hyperthermia has no role in this setting. Elevation of the head of the bed to 30 degrees increases venous drainage, thereby decreasing intravascular volume in the skull.7 In patients with a ventriculostomy, cerebrospinal fluid removal may be effective in reducing ICP.2 Mannitol (a hyperosmotic agent) may be used to decrease cerebral interstitial fluid.8 However, mannitol should not be used unless the child is hemodynamically stable or shows clinical or radiographic signs of impending herniation. Although mannitol can increase cerebral blood flow and decrease ICP in patients with head injury, prolonged administration may lead to intravascular dehydration, hypotension, and prerenal azotemia as well as a reduction of cerebral blood flow. The benefit of mannitol in head injured patients has yet to be determined. Pentobarbital may be used to control agitation and thus prevent further elevation of ICP.

    6. Marion DW, Penrod LE, Kelsey SF, et al. Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med 1997;336:540–6.

    7. Caniano DA, Nugent SK, Rogers MC, Haller JA. Intracranial pressure monitoring in the management of the pediatric trauma patient. J Pediatr Surg 1980;15:537–42.

    8. Chesnut RM. Th e management of severe traumatic brain injury. Emerg Med Clin North Am 1997;15:581–604.

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