Synopsis
Apply immediate positioning and physiological protection in an intracranial pressure crisis while keeping numerical ICP, perfusion, blood-pressure and ventilation targets tied to the correct age and aetiology.
- Start with airway, breathing and circulation; ENLS Version 6.0 advises SpO2 above 94% for an ICP crisis, head elevation above 30 degrees, neutral midline head position, normothermia, analgesia and correction of hyponatraemia.
- Positioning must respect cervical-spine precautions and haemodynamics: preserve alignment, loosen avoidable jugular obstruction and reassess blood pressure and neurological signs after elevation.
- For adults with severe TBI, BTF recommends treating ICP above 22 mmHg and targeting CPP 60 to 70 mmHg; SBP minima are at least 100 mmHg at age 50 to 69 and at least 110 mmHg at age 15 to 49 or over 70.
Key red flags
Falling consciousness, new anisocoria, impaired pupil reactivity, focal weakness, posturing or abnormal breathing requires immediate herniation treatment rather than routine optimisation.
Hypoxaemia, hypotension, fever, hypercapnia, hyponatraemia, pain, coughing, shivering or ventilator dyssynchrony can worsen intracranial physiology and require active correction.
Neck flexion, rotation, a tight cervical collar, obstructed jugular drainage or a head-down position may impair cerebral venous return.
Profound or prolonged hypocapnia can reduce cerebral blood flow and cause ischaemia; hyperventilation is a temporary rescue manoeuvre, not preventive treatment.
Hyperosmolar therapy without sodium, chloride, renal, fluid and osmolar monitoring can cause important harm, and agent preference differs between neurological aetiologies.
Adult severe-TBI SBP, ICP and CPP targets must not be transferred unchanged to children, IIH, tumour, spontaneous haemorrhage or hepatic encephalopathy.
Look immediately for hypoxaemia, hypotension, hypercapnia, fever, seizures, agitation, pain, coughing and shivering. These can increase blood volume or metabolic demand and are often reversible while definitive care is mobilised.
A falling GCS, new dilated pupil, focal weakness, posturing or abnormal respiration requires an emergency response. Do not postpone rescue measures while waiting for invasive ICP monitoring or the complete Cushing triad.
Use examination and urgent imaging to identify evacuable haemorrhage, obstructive hydrocephalus, mass lesion or diffuse swelling. Failure to improve after first-tier measures increases urgency for drainage, decompression or lesion evacuation.
Reasoning priorities
Detect hypoxaemia and hypotension promptly and quantify the circulatory effect of positioning, sedation and osmotherapy.
ENLS uses SpO2 above 94% during ICP crisis. Adult severe-TBI BTF SBP minima are age-banded; these should not be substituted for a child’s or non-traumatic patient’s individual resuscitation goals.
Worked reasoning
An adult with acute brain injury becomes drowsy and develops anisocoria while definitive imaging and neurosurgical review are being arranged.
- Call emergency, anaesthetic, neurocritical and neurosurgical teams; assess airway, breathing and circulation, apply oxygen to keep saturation above 94%, attach continuous monitoring and prevent hypotension during airway management.
- Raise the head of bed above 30 degrees and keep the head midline if circulation and suspected spinal injury permit, correct avoidable neck compression, minimise stimulation and provide adequate analgesia and sedation with repeated pressure checks.
- Target routine normocapnia and correct fever, hypoxaemia, hypotension and hyponatraemia; if active herniation persists despite immediate measures, an experienced team may use brief controlled hyperventilation to PaCO2 32 to 35 mmHg while definitive treatment proceeds.
- Use cause-appropriate hyperosmolar therapy and monitoring, obtain CT as soon as safe and progress without delay to evacuation, CSF diversion or decompression when indicated.
- Verify effect after every step through pupils, motor response, SpO2, arterial pressure, blood gas and ICP or CPP when monitored; deterioration despite improved numbers requires renewed imaging and source control.