Increased ICP: Recognition → Intervention Hierarchy — When to Escalate

Does the patient show EARLY signs of increased ICP?

• Assess for: restlessness, confusion, headache (worst in morning), projectile vomiting, pupil changes (sluggish ipsilateral), decreasing GCS
• Late/ominous signs (Cushing's triad): bradycardia + widening pulse pressure (hypertension) + irregular respirations → indicates brainstem compression, herniation imminent
• If ANY early signs present or ICP monitor reads > 20 mmHg → begin Step 1 immediately

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Step 1: Positioning & Environmental Controls (FIRST-LINE, always)

• Elevate HOB 30 degrees

• Maintain head in midline (no neck flexion or rotation — impedes jugular venous drainage)

• Avoid hip flexion > 90 degrees

• Prevent Valsalva: no straining, coughing, or bearing down — administer stool softeners prophylactically

• Minimize stimulation: dim lights, cluster care, limit suctioning to < 10 seconds per pass

• Maintain normothermia (fever increases cerebral metabolic demand)

• Do NOT: place in Trendelenburg, clamp EVD during repositioning without orders

• Expected response: ICP should decrease within minutes

• Not responding? ICP remains > 20 mmHg → proceed to Step 2

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Step 2: Osmotic Diuretic — Mannitol (20% IV)

• Draws fluid from brain tissue into vasculature → reduces cerebral edema

• Administer via filter needle (crystals form)

• Monitor serum osmolality: hold if ≥ 320 mOsm/kg (risk of renal failure)

• Monitor strict I&O — insert Foley; expect large urine output

• Check electrolytes frequently (Na+, K+)

• Do NOT: give if patient is hypotensive or dehydrated — mannitol worsens hypovolemia

• Expected response: ICP decrease within 15-30 minutes, peak effect ~1 hour

• Still rising? ICP > 20 mmHg despite mannitol → proceed to Step 3

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Step 3: Hypertonic Saline (3% NaCl)

• Expands intravascular volume and pulls fluid from edematous brain tissue

• Administer via central line only (highly irritating to peripheral veins)

• Monitor serum sodium closely — target Na+ 145-155 mEq/L; monitor serum osmolality

• Advantage over mannitol: does not cause hypotension; safer in hypovolemic patients

• Do NOT: administer through a peripheral IV

• Expected response: ICP reduction within 15-30 minutes

• Still rising? → proceed to Step 4

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Step 4: Controlled Hyperventilation (TEMPORARY BRIDGE ONLY)

• Mechanical ventilation to target PaCO2 30-35 mmHg (mild hypocapnia)

• Mechanism: low CO2 → cerebral vasoconstriction → decreased cerebral blood volume → decreased ICP

• Time-limited: effective for minutes to hours only — cerebral vessels reset, rebound vasodilation occurs

• Use ONLY as a bridge while preparing for surgery

• Do NOT: target PaCO2 < 25 mmHg (causes dangerous cerebral ischemia)

• Do NOT: use as a sustained management strategy

• ICP still uncontrolled? → proceed to Step 5

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Step 5: Notify Neurosurgeon — Surgical Intervention

• Decompressive craniectomy: removal of bone flap to allow brain to expand
• EVD (external ventricular drain) placement or adjustment: CSF drainage to mechanically reduce ICP
• Nurse's role: maintain EVD at prescribed level (usually tragus of ear), monitor drainage color/amount, strict aseptic technique, neuro checks every 1 hour minimum
• Do NOT: lower EVD collection system abruptly (rapid CSF drainage → ventricular collapse)

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At EVERY step — Continuous Monitoring:

• Neuro checks (GCS, pupil size/reactivity) every 15-60 min per protocol
• ICP waveform: normal = A waves absent; sustained plateau (Lundberg A) waves > 50 mmHg = emergency
• Calculate CPP = MAP − ICP → maintain CPP ≥ 60 mmHg (adequate cerebral perfusion)
• If CPP drops below 60: may need vasopressors to raise MAP while continuing ICP-lowering measures