Updates on the Use of Osmotherapy in the Emergency Department

Elevated intracranial pressure (ICP) is a critical condition associated with significant morbidity and mortality, requiring prompt and effective management. Mannitol and hypertonic saline (HTS) are the two most widely used hyperosmolar agents in clinical practice for ICP reduction, each with distinct pharmacologic properties, efficacy profiles, and safety considerations. This review aims to provide a comprehensive assessment of the mechanisms, clinical efficacy, safety, practical considerations, and guideline recommendations associated with the use of mannitol and HTS for the management of elevated ICP. Current available data does not clearly support one hyperosmolar agent over another and both agents are considered equivalent. Consensus recommendations vary, but the most recent recommendations seem to support the use of HTS over mannitol, mostly due to potential pharmacodynamic advantages that have been shown in smaller investigations. Further research is warranted to refine dosing strategies, clarify administration concerns, and address knowledge gaps in comparative efficacy and safety.