MBBS OSCE · General Medicine
OSCE — Raised Intracranial Pressure
Eight-minute OSCE station on Raised Intracranial Pressure: focused history, examination priorities, investigations, emergency and definitive management.
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Brief (to candidate)
You will assess a patient with a presentation consistent with Raised Intracranial Pressure.
You have 8 minutes to take a focused history, outline examination, investigations, and management including red flags.[1]
Clinical context
Raised intracranial pressure (ICP) occurs when the volume of brain, blood or CSF exceeds the rigid skull's capacity (Monro-Kellie doctrine; textbook 80/10/10 is conventional teaching). Typical adult ICP is 5 to 15 mmHg; in traumatic brain injury the Brain Trauma Foundation 4th edition (2016/2017) treats a sustained ICP above 22 mmHg. Causes include space-occupying lesions (tumour, haematoma, abscess), hydrocephalus (obstructive and communicating), cerebral oedema (vasogenic, cytotoxic, osmotic), traumatic brain injury, cerebral venous sinus thrombosis and idiopathic intracranial hypertension (IIH). Presentation: headache (worse on waking, coughing, bending), nausea and vomiting, papilloedema, altered consciousness, and the Cushing triad (bradycardia, hypertension, irregular breathing) as a late pre-terminal sign. Emergency bundle: head up 30 degrees, defend the age-stratified BTF SBP floor, Godoy PaCO2 35 to 40 mmHg with SpO2 ≥95 percent or PaO2 ≥80 mmHg, osmotherapy (emergency mannitol 0.5 to 1 g/kg or hypertonic saline 3 percent / 23.4 percent 30 to 60 mL; a 250 mL 3 percent bolus is unit practice), CT before LP, no corticosteroids in TBI.[1][2][3][4]
Candidate tasks
- Clarify onset, severity, associated features, and red-flag symptoms.
- State focused examination priorities.
- List first-line investigations and any named score/criteria.
- Give immediate resuscitation steps.
- Outline definitive management with doses/routes where standard.
- Name complications and disposition (ward / HDU / theatre / discharge safety-net).
- Mention one special-population modifier (pregnancy, child, elderly, CKD).[1]
Examiner checklist
| Domain | Pass behaviours |
|---|---|
| Definition | Correct working diagnosis language |
| Assessment | Focused, prioritised, red flags sought |
| Investigations | Appropriate first-line + interpretation |
| Emergency care | ABC / time-critical actions first |
| Definitive care | Specific drugs/procedures, not generic phrases |
| Safety | Headache worse on waking, coughing or bending — raised ICP; urgent CT |
| Safety | Papilloedema on fundoscopy — raised ICP; urgent imaging and neurology |
| Safety | Cushing's triad (bradycardia, hypertension, irregular breathing) — impending her |
| Communication | Clear plan and safety-netting |
Model outline
Lead with the working diagnosis and life threats. Resuscitate before definitive tests when unstable. Use guideline-standard therapy with named agents and doses. Document escalation criteria and follow-up. A safe candidate is specific, structured, and never delays critical care for non-urgent imaging.[1]
References4ShowHide
- [1]Kareemi H, Pratte M, English S, Hendin A. Initial Diagnosis and Management of Acutely Elevated Intracranial Pressure J Intensive Care Med, 2023.PMID 36802976
- [2]Kim H. Anesthetic management of the traumatic brain injury patients undergoing non-neurosurgery Anesth Pain Med (Seoul), 2023.PMID 37183278
- [3]Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension Front Neurol, 2017.PMID 28769857
- [4]Ramesh Kumar R, Singhi SC, Singhi P. Raised intracranial pressure (ICP): management in emergency department Indian J Pediatr, 2012.PMID 22218806