UMEM Educational Pearls

Management of the patient with intracranial hypertension represents one of the most challenging situations the emergency physician faces. Doing so in a community setting when the patient is a child is even more daunting. But devising therapies that can safely be given while the patient is being transferred to a tertiary center for definitive therapy is truly cringe-inducing. 
Fortunately, a recent study suggests that 3% saline fits this bill nicely. Given the risk of vasconstriction with hyperventilation and the risk of hypovolemia with mannitol, hypertonic saline has gained has emerged as beneficial therapy when trying to decrease intracranial pressure (ICP) in both children and adults. 
In late 2011, the Loma Linda University Medical Center published a retrospective analysis of their experience using 3% saline during transport of children at risk of elevated ICPs. While they found the expected rise in electrolytes such as sodium, chloride and bicarbonate, importantly they found no adverse effects (such as "local effects, renal abnormalities or central pontine myelinolysis") related to the administration of hypertonic saline, even though 96% of patients received the infusion through a peripheral line.
Bottom line: hypertonic saline appears to be a viable and safe option for use as therapy to decrease ICH during transport of children at risk for intracranial hypertension.

Luu JL, Wendtland CL, Gross MF, et al. Three percent saline administration during pediatric critical care transport. Ped Emerg Care 2011;27(12):1113-1117