Raised ICP, neurotrauma and brain-stem death

ICP and CPP targets: tiered management

Reviewed Nov 2026·5 references
New· views rounded down, updated weekly

Recognise raised ICP, set ICP and CPP targets, and escalate through the SIBICC tiers from basic neuroprotection to decompressive craniectomy.

Definition
Normal ICP 5-15 mmHg. Treat sustained ICP > 22 mmHg (BTF 4th edition). CPP = MAP - ICP; target 60-70 mmHg in TBI. Signs of herniation: unilateral dilated pupil, extensor posturing, Cushing response (hypertension, bradycardia, irregular breathing).

At the bedside

Timed steps
  1. 1

    Tier 0 (all patients)

    Always

    Head up 30°, neck neutral (loosen ETT ties/collar), adequate analgesia and sedation, normothermia (avoid fever), SpO2 ≥ 94% (PaO2 > 80 mmHg), PaCO2 35-45 mmHg, Na ≥ 135-140 mmol/L, glucose 140-180 mg/dL, Hb ≥ 7 g/dL, seizure prophylaxis/treatment, MAP ≥ 80 mmHg or CPP ≥ 60 mmHg.

  2. 2

    Herniation: emergency bridge

    Immediate

    Hyperventilate briefly to PaCO2 30-35, give mannitol 1 g/kg or hypertonic saline bolus, urgent CT and neurosurgery.

  3. 3

    Tier 1

    CPP 60-70 mmHg; deepen sedation/analgesia; intermittent mannitol or hypertonic saline boluses; CSF drainage if EVD present; consider continuous EEG; PaCO2 low-normal 35-38 mmHg.

  4. 4

    Tier 2

    Mild hypocapnia PaCO2 32-35 mmHg; neuromuscular blockade trial; MAP challenge to assess autoregulation (raise MAP with vasopressor, observe ICP); raise CPP if it lowers ICP.

  5. 5

    Tier 3

    Barbiturate (thiopentone) coma if haemodynamically tolerated; secondary decompressive craniectomy; mild hypothermia (35-36 °C) as last resort.

  6. 6

    Avoid harmful measures

    No steroids in TBI (CRASH: increased mortality); no prophylactic hypothermia; no prolonged hyperventilation PaCO2 < 30 mmHg; avoid hypotension (single SBP < 90 doubles mortality).

Osmotherapy

Mannitol 20%

IV
Dose
0.25-1 g/kg over 15-20 min
Worked example
70 kg: 1 g/kg = 70 g = 350 mL of 20% mannitol over 20 min

Replace urine losses; check osmolar gap before repeating.

Osmotherapy (preferred if hypotensive/hypovolaemic)

Hypertonic saline (3% or higher)

IV
Dose
3% NaCl 2-5 mL/kg over 10-20 min
Target
Na 145-155 mmol/L
Worked example
70 kg: 250 mL of 3% over 15 min

Maintain CPP

Noradrenaline

IV
Dose
0.05-0.5 mcg/kg/min
Preparation
4 mg in 50 mL = 80 mcg/mL
Target
CPP 60-70 mmHg
Worked example
70 kg at 0.1 mcg/kg/min = 5.25 mL/h
Open infusion calculator

SIBICC tiered ICP management (summary)

TierInterventions
0Head up 30°, analgesia/sedation, normothermia, SpO2/PaCO2/Na/glucose targets, CPP ≥ 60 or MAP ≥ 80
1CPP 60-70, deeper sedation, osmotherapy boluses, CSF drainage, PaCO2 35-38, consider EEG
2PaCO2 32-35, neuromuscular blockade, MAP challenge
3Barbiturate coma, secondary decompressive craniectomy, hypothermia 35-36 °C
Red flag · call your senior now
New unilateral fixed dilated pupil or sudden GCS drop ≥ 2: herniation emergency - osmotherapy, brief hyperventilation, urgent CT and neurosurgery.
Red flag
Cushing triad (hypertension, bradycardia, irregular breathing) is a late pre-terminal sign.
Pitfall
Lowering the BP of a hypertensive TBI patient with Cushing response: this may be maintaining CPP.
Pitfall
Tight ETT ties and cervical collars obstruct jugular venous drainage and raise ICP.
Pearl
Without an ICP monitor, use serial clinical exam, pupils (pupillometry), CT and optic nerve sheath diameter (> 5.7-6 mm suggests raised ICP) to guide therapy.

Calculators for this topic

Mean arterial pressure

(SBP + 2 × DBP) ÷ 3 (estimate; use the arterial line value when available).

Glasgow Coma Scale

Eye + Verbal + Motor (3-15). Record components, e.g. E3 V4 M5.

Infusion rate from mcg/kg/min

Pump rate in mL/h for drugs dosed in mcg/kg/min (noradrenaline, adrenaline, dobutamine, milrinone, nitroglycerin by weight).

References

  1. 1

    Carney N, Totten AM, O'Reilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery 2017;80:6-15.

  2. 2

    Hawryluk GWJ, Aguilera S, Buki A, et al. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med 2019;45:1783-94.

  3. 3

    Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of decompressive craniectomy for traumatic intracranial hypertension (RESCUEicp). N Engl J Med 2016;375:1119-30.

  4. 4

    Andrews PJD, Sinclair HL, Rodriguez A, et al. Hypothermia for intracranial hypertension after traumatic brain injury (Eurotherm3235). N Engl J Med 2015;373:2403-12.

  5. 5

    CRASH trial collaborators. Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial). Lancet 2004;364:1321-8.

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Osmotherapy: mannitol vs hypertonic saline

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.