How would you manage this patient in the intensive care unit?

The computed tomography (CT) scan shows a large left thalamic hemorrhage with intraventricular blood and a mild midline shift. The patient remains comatose. How would you manage this patient in the intensive care unit?

·  Maintain cardiorespiratory function

o   Fluid resuscitation.

o   Vasopressors or inotropes as needed.

o   Mechanical ventilation.

·  Decrease ICP

·        Elevate the head 30°.

·        Avoid positive end-expiratory pressure (PEEP), which may increase central venous pressure (CVP) and decrease blood return from the brain.

·        Administer mannitol (0.5–1 g/kg IV) for acute intracra-nial hypertension to raise the serum osmotic pressure.

·        Hyperventilation used to be routine practice. However, it has been shown to increase the risk of brain ischemia, therefore, ventilator settings should aim at normocapnia. Hyperventilation to a PaCO₂ of 25–30 mmHg can be used if there is an acute deterioration.

·        Consider insertion of an ICP monitor (e.g., a ventricu-lostomy), which also permits withdrawal of cerebro-spinal fluid in case of acute intracranial hypertension.

·        In extreme cases, a salvage craniectomy can be performed to remove part of the skull vault to control the ICP.

·  Avoid rebleeding

·        Control of the systolic blood pressure (SBP). Avoid SBP >160 mmHg.

·        Cerebral perfusion pressure (CPP) should be main-tained >70 mmHg. CPP is calculated by subtracting the CVP or ICP (whichever is the higher value) from the mean arterial pressure. Although data are available only for closed head injury, the potential for further ischemic damage in areas where autoregulation is abolished exists with most intracranial lesions.

·        Correct any coagulopathy.

·        Do not use anticoagulants.

·  Prevent seizures

·        Administer fosphenytoin 1500 mg IV (equivalent to 1000 mg of phenytoin) over 30 minutes, then phenytoin 100 mg IV every 8 hours, adjusted based on plasma levels.

·  Prevent hyperthermia

·        While the cerebral protective effect of hypothermia is still controversial, the deleterious effect of hyperther-mia on the injured brain is well established.

·        Administer antipyretics and active cooling as needed.

·  Prevent gastrointestinal bleeding

·        Administer anti-H₂ agents (e.g., famotidine 20 mg IV every 12 hours).

·  Prevent deep venous thrombosis

·        Sequential compression stockings.