CNS Mass Lesions

CNS Mass Lesions is a topic covered in the Pocket ICU Management.

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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)

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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)

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Last updated: April 14, 2010