ICP - earliest management

 Q: All of the following are the earliest bedside interventions in elevated Intracranial Pressure (ICP) secondary to intracranial hemorrhage (ICH) EXCEPT?

A) Elevation of  the head of the bed (HOB) to 30 degrees 

B) Sedation/analgesia for comfort 

C) Avoidance of endotracheal tube holder too tight

D) Normal saline for maintenance intravenous fluids (IVF) 

E) Glucocorticoids

Answer: E

Although sounds very simple but earliest interventions in high ICP play the highest modifying role in the trajectory of the outcome. Steroids have been suggested anecdotally as an intervention to reduce edema or inflammation due to high ICP in ICH but studies have shown no benefit. They are of benefit only in conditions where high ICP is due to an established inflammatory cause. Also, they can be judiciously used along with acetazolamide in patients who also develop severe papilledema. One of the less well-known dangers of steroids in high ICP is the rebound phenomenon during the tapering of the steroids. 

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References:

1. Poungvarin N, Bhoopat W, Viriyavejakul A, et al. Effects of dexamethasone in primary supratentorial intracerebral hemorrhage. N Engl J Med 1987; 316:1229. 

2. Friedman DI, Jacobson DM. Idiopathic intracranial hypertension. J Neuroophthalmol. 2004 Jun. 24(2):138-45.