Raised intracranial pressure — assessment and emergency management

Recognition. The combination of progressive morning headache with vomiting, papilloedema and a decreased conscious level is raised intracranial pressure. The blood pressure of 180/95 with a heart rate of 48 and irregular respiration is the Cushing triad — a late, pre-terminal sign meaning cerebral herniation is imminent or underway. Act now.

Airway. The patient is drowsy with an irregular respiratory pattern — protect the airway. Intubate early (rapid-sequence induction with a neuroprotective agent) if the GCS is 8 or below or the airway or oxygenation cannot be maintained.^[1]

Breathing. Ventilate to normocapnia — a PaCO2 of 35 to 40 mmHg. Do NOT prophylactically hyperventilate. Maintain the oxygenation at or above 95 per cent (or PaO2 ≥80 mmHg).^[2]

Circulation. Defend CPP at 60 to 70 mmHg. BTF 4th-edition SBP floors are age-stratified: ≥100 mmHg if aged 50 to 69 years, ≥110 mmHg if aged 15 to 49 or over 70. The Cushing hypertension does NOT mean you lower the pressure. Positioning and tier-1 measures. Elevate the head to 30 degrees with the head neutral to aid the venous drainage. Ensure sedation and analgesia, normothermia, normoglycaemia, and seizure control.^[12]

Osmolar therapy. Give mannitol 0.5 to 1 g per kg intravenously (2.5 to 5 mL/kg of 20%) OR hypertonic saline (3 per cent, or 23.4 per cent 30 to 60 mL) immediately as a bridge to definitive treatment. A historical caution is to watch osmolarity because mannitol may precipitate AKI above 320 mOsm per L.^[1]

Investigation. An urgent CT head (once intubated and stable for transfer) to identify the cause — a tumour, haematoma, abscess, or hydrocephalus — and to show the midline shift and the effaced basal cisterns. NEVER perform a lumbar puncture when raised ICP is suspected.^[1]

Disposition. Call the neurosurgeon immediately. Admit to a neurosurgical or intensive-care bed with an intracranial-pressure monitor. For a tumour with vasogenic oedema, add dexamethasone (4 to 8 mg/day if mild symptoms; 16 mg/day or more if severe mass effect — Ryken, metastases) — but do NOT give steroids if the cause is trauma (CRASH: 21.1% vs 17.9% 2-week mortality).^[16][4]