First Things First (assess & treat for the following)

Stabilization

• Aspiration precautions/rescue position vs. airway protection/intubation
  • Glasgow Coma Scale (GCS) score < 8, head/neck/chest trauma, sig. cardiopulmonary disease, etc.: consider intubation
• Adequate oxygenation/ventilation
• C-spine protection/precautions (trauma)
• Control seizures: phenytoin, barbiturates, benzodiazepines, levetiracetam
• Cerebral perfusion pressure (CPP) maintenance
• Hypotension: cautious volume repletion w/ normal saline (NS)
• HTN: cautious IV antihypertensive therapy (labetalol, esmolol) to 160-180/80-90 level
• Consider ICP-lowering maneuvers:
  • Elevate head of bed 30 degrees w/ neck neutral.
  • Modest hyperventilation to PaCO2 30-35 mmHg (if intubated)
  • IV mannitol bolus (0.25-0.50 mg/kg)
  • IV glucocorticoids (dexamethasone 10 mg), especially for malignancy
  • IV sedation (propofol 25-50 mcg/kg/min; midazolam 2-4 mg/hr, dexmedetomidine 0.2-0.4 mcg/kg/hr)
    • Impairs serial neuro exams (least with dexmedetomidine)
  • IV paralysis (rocuronium 0.6 mg/kg, cisatracurium 0.2 mg/kg)
    • Impairs serial neuro exams

Global strategy: the 8 Ds:

• Detection (history & physical)
• Data (CT, MRI, C-spine imaging, coags, lytes, ABG, CBC, drug levels)
• Differential diagnosis
• Decision
  • Drugs (mannitol, steroids, sedation/paralysis, antibiotics, vitamin K, plasma/platelets)
  • Drainage (craniotomy/burr hole, external ventricular drain [EVD])
  • Discontinue (terminal/irreversible disease, brain death)
  • Donate organs (brain death)