The newest installment in the popular ALiEMU Capsules series is live. This module focuses on the critical care topic of intracranial pressure management. Specific topics include hyperosmolar therapy with mannitol versus hypertonic saline and blood pressure management. Go to the ALiEMU Capsule and take the quiz for your Capsules certificate.


Patients presenting to the emergency department with new intracranial hemorrhage require prompt management to improve functional outcomes. These patients frequently require airway protection, however, rapid sequence intubation (RSI) can raise intracranial pressure (ICP) via direct effects of medications and reflexive responses from manipulation of the upper airway. Fentanyl can blunt the sympathetic response of laryngoscopy; however, use should be avoided in hypotensive or hypovolemic patients.1 The literature evaluating the effects of lidocaine on increased ICP are inconsistent and it is no longer recommended as pretreatment.2,3

Intracranial hemorrhage with signs of cerebral edema or hypertension should be evaluated for early hyperosmolar therapy and targeted blood pressure management, respectively. For both of these indications, several agents are available and selection is based on a variety of factors. The use of hyperosmolar agents for intracranial hypertension remains the mainstay of therapy for patients with cerebral edema. Patients with ICPs that remain elevated despite hyperosmolar therapy may be initiated on barbiturates and other sedatives. Propofol has demonstrated good outcomes for ICP control and is considered the drug of choice in these patients to allow for frequent neurologic exams. However, since propofol possesses no analgesic properties it should be combined with continuous or intermittent opioids.4

The latest Capsule module delves into the differences between agents for treating cerebral edema, blood pressure goals in the setting of intracranial hemorrhage, and the various antihypertensive agents used to achieve those goals.

Learning Objectives

  1. Evaluate different hyperosmolar agents for reducing intracranial pressure
  2. Select goal systolic blood pressure targets based on type of neurologic injury
  3. Design an antihypertensive regimen incorporating patient specific factors to achieve recommended blood pressure goals

Course Contributors

Jamie M. Rosini, PharmD, MS, BCPS, BCCCP, DABATEmergency Medicine Pharmacist, Christiana Care Health System@jrozzini
Ashley N. Martinelli, PharmD, BCCCPEmergency Medicine Pharmacist, University of Maryland Medical Center@RxMartinelli
PharmD Reviewer: Glenn Oettinger, PharmDThomas Jefferson University Hospital@glennoettinger
Emily Wiener, PharmD (Copy Editor)Emergency Medicine Pharmacist, Baltimore Washington Medical Center@PharmdEMily
Nadia Awad, PharmD, BCPS (Associate Editor)Emergency Medicine Pharmacist, Robert Wood Johnson University Hospital@Nadia_EMPharmD
Bryan Hayes, PharmD, FAACT, FASHP (Lead Editor)Clinical Pharmacy Manager, Massachusetts General Hospital@PharmERToxGuy



  1. 1.
    Splinter W, Cervenko F. Haemodynamic responses to laryngoscopy and tracheal intubation in geriatric patients: effects of fentanyl, lidocaine and thiopentone. Can J Anaesth. 1989;36(4):370-376.
  2. 2.
    Chraemmer-Jørgensen B, Høilund-Carlsen P, Marving J, Christensen V. Lack of effect of intravenous lidocaine on hemodynamic responses to rapid sequence induction of general anesthesia: a double-blind controlled clinical trial. Anesth Analg. 1986;65(10):1037-1041.
  3. 3.
    Kelly D, Goodale D, Williams J, et al. Propofol in the treatment of moderate and severe head injury: a randomized, prospective double-blinded pilot trial. J Neurosurg. 1999;90(6):1042-1052.
  4. 4.
    Helfman S, Gold M, DeLisser E, Herrington C. Which drug prevents tachycardia and hypertension associated with tracheal intubation: lidocaine, fentanyl, or esmolol? Anesth Analg. 1991;72(4):482-486.
Michelle Lin, MD
ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco
Michelle Lin, MD


Professor of Emerg Med at UCSF-Zuckerberg SF General. ALiEM Founder @aliemteam #PostitPearls at Bio:
Michelle Lin, MD