A patient with severe closed head injury has a GCS of 8 and ICP monitoring shows sustained ICP of 28 mmHg despite head elevation, sedation, and normoventilation. The next tier of ICP-directed therapy after osmotic therapy (mannitol/hypertonic saline) is:

• A Therapeutic hypothermia to 33°C
• B Decompressive craniectomy
• C Hyperventilation to PaCO2 of 25 mmHg
• D Barbiturate coma (pentobarbital/thiopentone) ✓

Explanation

For refractory raised ICP unresponsive to first-tier measures (head elevation, sedation/analgesia, CSF drainage, osmotic therapy), second-tier options include barbiturate coma (high-dose thiopentone or pentobarbital), decompressive craniectomy, and controlled hyperventilation. Current BTF (Brain Trauma Foundation) guidelines suggest barbiturate coma as a tier 2 intervention before decompressive craniectomy, though practice varies. Prolonged hyperventilation to PaCO2 <30 is harmful due to ischaemia from vasoconstriction.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.