3 Increased Intracranial Pressure
Recognize signs of rising intracranial pressure and possible herniation, interpret ICP readings, and prioritize urgent assessment and response.
Recognizing neurological deterioration
New restlessness, confusion, or reduced alertness may be early signs of neurological deterioration and rising (ICP). Compare findings with the patient’s baseline and promptly report significant changes; do not wait for late warning signs.
Warning signs of worsening pressure
A falling score, new pupil asymmetry or reduced reactivity, and extensor posturing may indicate worsening intracranial hypertension or impending . A sudden decline in consciousness accompanied by a newly enlarged, nonreactive pupil and extensor posturing is an emergency warning pattern.
—hypertension, bradycardia, and irregular respirations—may also signal worsening intracranial hypertension or impending . It is often a late finding. Equal pupils alone do not establish that neurological status is stable.
Interpreting ICP readings
In adults, sustained (ICP) above mm Hg is generally treated as elevated. For example, a sustained reading of mm Hg exceeds this commonly used treatment threshold and calls for escalation and the prescribed ICP-management protocol.
Interpret readings alongside the patient’s examination and clinical context. Do not ignore an elevated reading because blood pressure is normal, and do not delay action for suspected while waiting for an invasive ICP monitor reading.
Priorities for urgent response
For acute neurological deterioration with suspected increased ICP:
Call for emergency help and notify the responsible provider or appropriate clinical team.
Rapidly assess and support airway, breathing, and circulation, while preventing hypoxia and hypotension.
Repeat and document the neurological examination, including GCS, pupils, and motor response.
Prepare for urgent diagnostic evaluation and prescribed ICP-lowering treatment.
When appropriate and not contraindicated, positioning the head elevated and midline may support venous drainage. Management under the prescribed protocol may also include cerebrospinal-fluid drainage when available or ordered hyperosmolar therapy. Routine prolonged hyperventilation is not recommended, and corticosteroids are not standard treatment for severe traumatic brain injury.