Signs of brain herniation suggestive of severely elevated ICP warrants rapid treatment.

• Cerebral perfusion pressure (CPP) can be conceptualized as the difference between the mean arterial pressure (MAP) and intracranial pressure (ICP).
• Elevation in ICP can result in reductions in CPP, leading to brain ischemia.
• Normal intracranial pressure is < 20 mm Hg.
• As the cranium is a fixed, rigid space, increases in volume within the cranial cavity results in increased ICP after compensatory mechanisms are exceeded.
• Elevated ICP can has various etiologies and can be broken down into:
  • Mass effect (blood, abscess, tumour)
  • Increased CSF
  • Decreased CSF resorption
  • Increased blood volume

• Elevated ICP should be suspected based on mechanism of injury, history and physical.
• Physical examination consistent with increased ICP including unilateral or bilaterally fixed, dilated pupils, decorticate or decerebrate posturing, and papilledema.
• Severe cases may present with Cushing’s triad: bradycardia, hypertension, and irregular respirations.
• Imaging with CT of the head (or MRI) can reveal signs of raised ICP and should be completed on all patients with suspected elevated ICP.
• The diagnosis of increased ICP is generally based on clinical findings and imaging, but in certain cases invasive ICP monitoring may be warranted for more close monitoring of ICP.

• Treatment should be focussed on relieving the underlying cause, such as evacuation of underlying hematoma or treatment of intracranial infection.
• Medical management:
  • Head of bed elevation to 30 degrees.
  • BP should be controlled to maintain cerebral perfusion pressure >60 mm Hg.
  • Avoid hypoxemia keeping PaO2 >60 mm Hg.
  • Sedation should be utilized to reduce metabolic demand. Propofol is most commonly used and titrated to desired effect 0-80 mcg/kg/min.
  • Osmotic therapy with either hypertonic saline to target Na 140-150 mEq/L, or mannitol bolused at 1g/kg with repeat doses at 0.25 g/kg to 0.5 g/kg as required.
  • Antipyretics and cooling devices should be used to maintain temperature between 36 -37.5 Celsius.
• Surgical management:
  • External ventricular drain (EVD) can be placed to monitor ICP as well as drain CSF to reduce ICP.
  • Decompressive craniectomy may need to be performed in cases of severely elevated ICP with signs of herniation.

• All patients with elevated ICP secondary to trauma should be admitted to hospital, as well as any patient with a GCS less than 15.
• Discharge with outpatient management may be appropriate in more benign causes of increased ICP such as idiopathic intracranial hypertension.

• Patients with elevated ICP and changes in mental status should be transferred to centres with intensive care capabilities and neurosurgical specialists.
• Airway control with intubation should be considered prior to transport in all patients with reduced GCS.

• Patients with acute elevations in ICP should be observed and managed in an intensive care setting.
• Those with chronic elevations in ICP may be suitable for outpatient management depending on etiology.

Generally not applicable.

1. ECBC Traumatic Brain Injury Management Summary: https://emergencycarebc.ca/clinical_resource/traumatic-brain-injury-management/

   Arterial line placement – https://emergencycarebc.ca/clinical_resource/arterial-line-placement-radial-w-us/

   Central line placement – https://emergencycarebc.ca/clinical_resource/central-line-procedure-internal-jugular-ultrasound-guided/

   
   

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2. Ragland J, Lee K. Critical Care Management and Monitoring of Intracranial Pressure. J Neurocrit Care. 2016 Dec 28;9(2):105–12.

   
   

3. Freeman WD. Management of Intracranial Pressure. Continuum (Minneap Minn). 2015 Oct;21(5 Neurocritical Care):1299–323.

   
   

4. Evaluation and management of elevated intracranial pressure in adults – UpToDate [Internet]. [cited 2023 Dec 26]. Available from: https://www.uptodate.com/contents/evaluation-and-management-of-elevated-intracranial-pressure-in-adults?search=increased%20intracranial%20pressure&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2#H20