Adult Medical Emergency Handbook - Scottish Intensive Care Society

TENTORIAL HERNIATION AND CONING
• Raised ICP can cause this.
• Rapidly fatal but it is potentially reversible if identified and treated early.
• May occur post lumbar puncture but this is rare in patients with no
focal neurology or raised ICP
Diagnosis
• Intra-cranial pathology e.g. recent lumbar puncture in meningitis or
SAH, haematoma.
• Pupil(s) dilate abruptly, and fix.
• Respiration periodic or stertorous.
• Bradycardia and hypertension.
• Coma
Action
• Call 2222 then ICU and Neurosurgeon.
• Bag, mask, valve hyper-ventilate with high concentration oxygen.
• IV access.
• Mannitol 20% 200ml IV, furosemide 20mg IV, ALBA 200ml all stat.
• Require intubation and ventilation with anaesthetic.
• Further management will be decided by ICU and Neurosurgical
specialists.
FURTHER MANAGEMENT OF MENINGITIS
• Analgesia.
• IV fluids if volume deplete.
• Infection control for suspected meningococcal disease, isolate
patient for first 48h.
• Notify the on-call consultant in Public Health of all meningococcal
and Haemophilus influenzae infections. They will arrange
prophylaxis for all contacts, including the patient’s immediate
household contacts and any significantly exposed staff contacts
(mouth-to-mouth resuscitation or other close prolonged contact;
prophylaxis rarely necessary for staff).
ICU referral if:
• Shock unresponsive to fluid resuscitation.
• Respiratory failure.
• GCS