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P163: MANAGEMENT OF INTRACRANIAL PRESSURE CRISES DURING PRONE POSITIONING IN TRAUMATIC BRAIN INJURY PATIENTS WITH RESPIRATORY FAILURE
Alexander F Kuffer, MD, DMD, PhD; Michael Taylor, MD; Davide M Croci; Lakeland Regional Health

Traumatic brain injury (TBI) remains a leading cause of emergency admissions in the United States, accounting for approximately 586 hospitalizations and 190 deaths daily. Acute respiratory failure complicates about 17% of TBI cases and substantially increases in-hospital mortality. Since the COVID-19 pandemic, prone positioning has become standard care for patients with severe respiratory failure. However, in individuals with TBI and elevated intracranial pressure (ICP), proning may precipitate abrupt ICP deterioration despite maximal medical management.

Here we report the case of a 17-year-old female with diffuse axonal injury (DAI) and acute respiratory distress syndrome (ARDS) who developed critical ICP elevation following prone ventilation. Return to the supine position combined with initiation of extracorporeal membrane oxygenation (ECMO) led to rapid normalization of ICP and cerebral oxygenation. We review the pathophysiological mechanisms underlying ICP worsening during proning and propose a troubleshooting flowchart for managing ICP crises in this context. In patients unable to tolerate proning, ECMO represents a timely bailout strategy to stabilize cerebral physiology and optimize neurological outcomes.

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