POTD: Trauma Tuesday! Hyperosmolar Solutions for Traumatic Brain Injury

Clinical Scenario:  24 yo M BIBA after a MVC.  Patient was an unseatbelted passenger that was expelled from the vehicle.  Per EMS, patient had positive LOC at the scene, became more arousable on the way to the hospital, GCS13 with a hematoma on the left scalp.  While in the trauma bay, the patient loses consciousness with sluggish and dilated pupils.  He is bradycardic and hypertensive with irregular breathing (Cushing’s triad).  You are concerned that he is herniating with increased ICP and ask the nurse for a hypertonic solution while you prepare for intubation. Which hypertonic solution do you choose and how do you give it?
Two common choices are mannitol and hypertonic saline.
Mannitol is given as boluses of 0.25 to 1g/kg every 4-6 hours as needed.
Optimal dosing is not established for hypertonic saline; give in boluses through a central line, some protocols as per Uptodate include:
3%: 300mL given over 20 minutes when ICP >20mmHg (Huang 2006)
7.5%: 2mL/kg given over 20 minutes when ICP >25mmHg (Vialet 2003)
23.4%: 30mL given over 2 minutes (Ware 2005) or 30mL given over >30minutes when ICP values >20mmHg (Kerwin 2009)
So do you give mannitol or hypertonic saline?
A 2015 meta-analysis (Pelletier et al.) found no significant mortality benefit and no difference in neurologic outcome with giving hypertonic saline over other hyperosmolar solutions.  Mannitol has been the gold standard, but hypertonic saline’s volume expanding property over mannitol’s diuresis in a trauma patient has been a consideration.
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Wright DW, Merck LH. Head Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e New York, NY: McGraw-Hill; 2016. http://accessemergencymedicine.mhmedical.com/content.aspx?bookid=1658&sectionid=109445450. Accessed January 23, 2018.