Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 13 Sept 2026Clinical review pending
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Treat herniation clinically
A new fixed or dilating pupil, falling consciousness, posturing or respiratory irregularity can represent herniation even if no monitor is present, is reading normally or has questionable signal quality.
Action: Activate critical-care and neurosurgical response, manage airway and circulation, begin pressure-crisis measures and obtain urgent imaging when safe while checking the device; do not delay rescue to insert, re-zero or debate a monitor.
Synopsis
Select, interpret and troubleshoot invasive intracranial pressure monitoring as one part of cause-specific neurocritical care without turning severe-TBI thresholds into universal neurological rules.
ICP monitoring quantifies pressure and burden; it does not identify the cause, replace serial neurological examination or remove the need for repeat imaging when the patient deteriorates.
An EVD measures ventricular pressure and can drain CSF but carries infection, haemorrhage, obstruction and over-drainage risks; an intraparenchymal probe is easier to place in small ventricles but cannot drain and may drift.
Interpret each value with duration, waveform, reference level, head position, stimulation, sedation, pupils, motor response, MAP and imaging; treat the patient and verified trend.
Key red flags
A clinical herniation syndrome overrides an apparently normal or unavailable ICP number and demands immediate resuscitation and neurosurgical assessment.
Abrupt loss of waveform, implausible negative pressure, drift or a value inconsistent with pupils and imaging suggests device or reference error that must be checked.
A sustained rise with worsening pupils, motor response or CT findings has more weight than an isolated cough, suction or position-related spike.
Falling MAP can reduce cerebral perfusion even when ICP is unchanged; CPP is derived from both values and must be interpreted with age and aetiology.
CSF leak, purulent discharge, fever, catheter-tract haemorrhage or new focal deficit after insertion requires urgent device and intracranial complication assessment.
Clinical-monitor discordance
If pupils, consciousness or motor response worsen while ICP appears normal, presume the patient may be deteriorating. Check laterality, probe position and waveform while arranging imaging and treatment.
Procedural complication
Recognise new deficit, seizure, insertion-site bleeding, ventriculitis features, CSF leak, over-drainage headache or sudden cessation of drainage as reasons for immediate specialist review.
Investigation priorities
01
ICP value and time burdenFirst step
Quantify magnitude, duration and recurrence of intracranial hypertension and response to intervention.
Management branches
Interpretation pathwayA new ICP elevation
The monitor shows a new pressure rise or increasing pressure burden, with or without clinical change.
Look at the patient first: repeat pupils and motor response, review airway, oxygenation, ventilation, MAP, temperature, seizure activity, pain, agitation and recent stimulation.
Validate the signal: confirm the device type, waveform, zero and anatomical reference, head position, EVD clamp and height, connections, patency and whether the displayed value is transient or sustained.
National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 13 Sept 2026; clinical approval remains outstanding.
Brain Trauma Foundation severe TBI guideline, fourth editionCurrent BTF severe TBI recommendation index, fourth edition 2016 with 2020 decompressive-craniectomy update, read 13 September 2026: hyperosmolar therapy, ICP and CPP monitoring, thresholds, ventilation and CSF drainage. Applies to severe traumatic brain injury; older third-edition mannitol statements are explicitly identified by BTF as not supported by evidence meeting fourth-edition standards. Chapter-specific use: intracranial-pressure monitoring.
Brain Trauma Foundation paediatric severe TBI guideline, third editionCurrent BTF paediatric severe TBI recommendation index, third edition 2019, read 13 September 2026: ICP monitoring; neuroimaging limitations; paediatric ICP and CPP thresholds; hypertonic-saline regimens and safety; CSF drainage and ventilation. Applies only to children with severe traumatic brain injury and contains mainly weak recommendations. Chapter-specific use: intracranial-pressure monitoring.
Emergency Neurological Life Support Intracranial Hypertension and Herniation ProtocolNeurocritical Care Society ENLS version 6.0, last updated September 2024; communication checklist, diagnosis, Tier Zero, Tier One, Tier Two and Tier Three scope read 13 September 2026: crisis recognition, head elevation, SpO2, hyperosmolar treatment, short rescue hyperventilation, CSF drainage and definitive cause control. This multi-aetiology professional consensus protocol requires adaptation to age, aetiology, access and local critical-care protocol and does not make adult severe-TBI thresholds universal. Chapter-specific use: intracranial-pressure monitoring.
NCS evidence-based consensus statement on external ventricular drainsFried et al., Neurocritical Care 2016, DOI 10.1007/s12028-015-0224-8; full body read 13 September 2026: methods and paediatric exclusion, haemorrhagic and infectious complications, routine CSF sampling, catheter changes, weaning and removal, collection-system manipulation and EVD management bundles. The evidence questions and recommendations concern adults; primarily paediatric studies were excluded, many data are observational, and no quantitative paediatric device-care practice is inferred. Chapter-specific use: intracranial-pressure monitoring.
NICE NG240 bacterial meningitis and meningococcal diseasePublished 19 March 2024; recommendations 1.4.1 and 1.4.6–1.4.13 plus 1.9.3–1.9.7 read 13 September 2026: investigation/antibiotic sequence, imaging triggers, LP contraindications, temporary osmotic therapy and ICP-monitoring limits. Covers babies, children, young people and adults, with neonatal cross-referral where specified; it is meningitis-specific rather than a universal LP or ICP protocol. Chapter-specific use: intracranial-pressure monitoring.
NICE NG232 head injury assessment and early managementPublished 18 May 2023; recommendations 1.4.15–1.4.16, 1.8.4–1.8.16 and 1.9.9–1.9.17 read 13 September 2026: neurosurgical discussion, stabilised transfer, age boundaries, neurological observations and deterioration. Applies to traumatic head injury; observation schedules are not asserted for non-traumatic or postoperative patients. Chapter-specific use: intracranial-pressure monitoring.