Suspected raised ICP (adult)
Clinical signs or CT signs of raised intracranial pressure in an adult. Children: use paediatric guidance. Pregnancy: get obstetric input early.
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NeurologyEmergency
Increased Intracranial Pressure Management
Increased Intracranial Pressure Management: Suspected raised ICP (adult) → Recognise signs of raised ICP → Tier 0: prevent hypoxia and hypotension now →...
Pathway Overview
21 steps
Algorithm Steps
21 total
01Start 02Action Recognise signs of raised ICP
A normal early examination does not exclude raised ICP. Late signs mean herniation may be close.
- Headache, vomiting, papilloedema (may be absent in acute causes)
- Falling GCS or new confusion
- New pupil asymmetry or a dilated, unreactive pupil
- Abnormal flexion or extension posturing
- Cushing triad (late): hypertension, bradycardia, irregular breathing
03Action Tier 0: prevent hypoxia and hypotension now
Start at once in every patient, before and during imaging. These basic measures apply in all tiers.
- Intubate if GCS 8 or less or the airway is at risk; keep SpO2 94% or higher
- TBI: keep SBP 110 mmHg or higher (age 15-49 or over 70), or 100 mmHg or higher (age 50-69)
- Keep PaCO2 35-45 mmHg; do not hyperventilate routinely
- Head up 30-45 degrees, head midline, collar not tight (possible spinal injury: tilt the whole bed)
- Isotonic IV fluids only (no hypotonic fluids); avoid hyponatraemia; check glucose
- Treat pain and agitation; treat fever (core temperature above 38 C); treat seizures
- Arterial line for continuous BP; keep Hb above 70 g/L
- Call neurosurgery early; if none on site, call the retrieval service
04Warning Osmotherapy cautions (never delay treatment of herniation)
Choose the agent to suit the patient. Recheck sodium, osmolality and fluid balance after each dose.
- Hypotension, hypovolaemia or active bleeding: use hypertonic saline, not mannitol (mannitol causes diuresis)
- Anuria, acute kidney injury, heart failure or pulmonary oedema: avoid mannitol; hypertonic saline can overload fluid; get ICU advice
- Known chronic hyponatraemia: still treat herniation, then limit the sodium rise with specialist advice (risk of osmotic demyelination)
05Decision Signs of herniation or critical neuroworsening?
Yes if any: new dilated or unreactive pupil, fall in GCS motor score of 1 or more, new focal motor deficit, posturing, or Cushing triad.
- If Yes
06Action Herniation signs: give osmotherapy now
Emergency bridge to CT and definitive treatment. Do not wait for blood results.
- Adult: mannitol 20% 0.5-1 g/kg IV bolus (2.5-5 mL/kg; max 1 g/kg per dose)
- OR hypertonic saline IV bolus (strength and volume per local protocol). Do not wait for a central line: 3% can go into a large peripheral vein; 7.5% or stronger centrally when possible
- Hypotensive or hypovolaemic: use hypertonic saline, not mannitol
- Brief hyperventilation (less than 2 h) to PaCO2 30-35 mmHg only as a bridge
- Urgent neurosurgical review; check sodium, osmolality and glucose
07Action Urgent non-contrast CT head
All patients, as soon as airway, breathing and circulation are safe for transfer. Stable patients (no herniation signs) come here directly. No lumbar puncture or lumbar drain before CT.
- Mass lesion: haematoma, tumour, abscess, large infarct
- Hydrocephalus
- Oedema pattern, midline shift, effaced basal cisterns
- Lumbar puncture only if CT shows no mass effect, shift, effaced cisterns or obstructive hydrocephalus; never a lumbar drain for raised ICP
08Action Treat the cause found on CT
Some treatments help one cause and harm another.
- TBI or intracerebral haemorrhage: do not give corticosteroids (higher mortality in TBI, CRASH trial)
- Intracranial bleeding on an anticoagulant: reverse it urgently (see ICH pathway)
- Tumour or abscess with vasogenic oedema: dexamethasone (dose with neurosurgery or oncology)
- Bacterial meningitis: dexamethasone with antibiotics (see meningitis pathway)
- Spontaneous ICH or ischaemic stroke: BP targets per the ICH or stroke pathway (the TBI SBP floors do not apply)
- Acute liver failure, large stroke, or DKA in a young person: use the condition pathway
09Decision Lesion that needs surgery?
Yes if: extradural or subdural haematoma with mass effect, acute obstructive hydrocephalus, large haematoma or cerebellar lesion with mass effect, or tumour or abscess with herniation. Neurosurgery decides.
- If Yes
10Action Surgical lesion: emergency neurosurgery
Then to ICU, with ICP monitoring if the neurosurgeon advises.
- Craniotomy to evacuate the haematoma or mass
- EVD for acute obstructive hydrocephalus
- Resection or decompression of a mass lesion
- Primary decompressive craniectomy if the neurosurgeon decides
11Action ICU admission and ICP monitoring
No surgical lesion, or after surgery. Neurosurgery and ICU decide on a monitor.
- Severe TBI (GCS 3-8 after resuscitation) with abnormal CT: ICP monitoring advised
- EVD allows CSF drainage; a parenchymal probe is an alternative
- Treat ICP above 22 mmHg; keep CPP 60-70 mmHg
- No monitor: frequent neurological and pupil checks; repeat CT if worse
- Not at a neurosurgical centre: arrange transfer early
12Action Tier 1: ICP above 22 mmHg
Start with Tier 1. Use one or more items; there is no order within a tier.
- Keep CPP 60-70 mmHg; increase analgesia and sedation to lower ICP
- Drain CSF if an EVD is in place (consider an EVD if only a parenchymal probe)
- Adult: mannitol 0.25-1 g/kg IV as intermittent bolus, given for raised ICP (not scheduled, not an infusion)
- OR hypertonic saline as intermittent bolus (local protocol); if hypotensive, use hypertonic saline, not mannitol
- Stop osmotherapy doses if sodium is above 155 mmol/L or osmolality above 320 mOsm/kg
- Mannitol: check the osmolar gap (renal risk); hypertonic saline: check sodium, chloride and renal function
- PaCO2 35-38 mmHg; consider EEG; anti-seizure prophylaxis for 1 week only
13Decision ICP controlled on Tier 1?
Yes: ICP 22 mmHg or less with CPP 60 mmHg or more. No: reassess, then Tier 2.
- If Yes
14Action ICP controlled: maintain, then wean
Keep Tier 0 care and treat the cause.
- Wean one therapy at a time, slowly; watch for rebound ICP
- Watch for rebound ICP when osmotherapy stops
- Sedation holiday and ICP monitor removal: specialist decision (often after 72 h of acceptable ICP)
15Outcome Ongoing neurocritical care
ICU care continues until the monitor is removed and the cause is treated.
If No16Action ICP not controlled: reassess before you escalate
Do this each time you move up a tier.
- Re-examine; repeat CT; reconsider surgery for a lesion
- Look for extracranial causes: hypoxia, hypotension, fever, seizures, low sodium, pain, ventilator asynchrony
- Check the basic targets (CPP, blood gases)
- Discuss with, or transfer to, a specialist neurotrauma centre
17Action Tier 2: ICP still above 22 mmHg after Tier 1
Specialist ICU care.
- Mild hypocapnia: PaCO2 32-35 mmHg; do not go below 30 mmHg routinely
- Neuromuscular blockade only if adequately sedated; give a trial dose and continue only if ICP falls
- MAP challenge: raise MAP by 10 mmHg for up to 20 min, with a doctor at the bedside who can stop it
- Autoregulation intact: raise CPP with fluid, vasopressor or inotrope to lower ICP
- Do not routinely raise CPP above 90 mmHg
18Decision ICP controlled on Tier 2?
Yes: ICP 22 mmHg or less with CPP 60 mmHg or more. No: reassess again, then Tier 3.
- If Yes
- Path rejoins step 14Shared downstream outcome
If No19Action Tier 3: ICP refractory to Tier 2 (specialist decision)
Highest-risk treatments. Repeat CT and reconsider surgery first.
- Secondary decompressive craniectomy (large fronto-temporo-parietal, at least 12 x 15 cm)
- Barbiturate coma (thiopentone in Australia): test dose first; continue only if ICP falls; EEG monitoring; avoid hypotension
- Titrate barbiturate to ICP control; do not increase the dose beyond burst suppression. Dose: specialist ICU protocol
- Mild hypothermia 35-36 C with active cooling; do not cool below 35 C
20Decision ICP controlled on Tier 3?
Yes: maintain and wean. No: senior review.
- If Yes
- Path rejoins step 14Shared downstream outcome
If No21Outcome Refractory ICP despite Tier 3: senior review
Senior neurosurgery and ICU review for missed causes and further surgery. Discuss prognosis and goals of care with the family.
If No- Path rejoins step 11Shared downstream outcome
If No- Path rejoins step 07Shared downstream outcome
Guideline Source
Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC): management algorithm for patients with ICP monitoring (Hawryluk et al, Intensive Care Med 2019)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only. Tiers are from severe TBI consensus (SIBICC 2019); other causes (stroke, ICH, tumour, liver failure) need cause-specific care
- Hypertonic saline strength and volume, and barbiturate doses, follow the local ICU protocol
- ICP monitoring and Tier 2-3 therapies need a neurosurgical ICU
- Evidence for most ICP therapies is low quality or consensus
Contraindicated Populations
Children and adolescents under 16: use paediatric TBI and raised ICP guidancePregnancy: obstetric and neurosurgical input; this pathway does not cover pregnancy changesAcute liver failure, diabetic ketoacidosis cerebral oedema and malignant stroke oedema: use the condition-specific pathway
Applicable Regions
AUUSEUglobal
AU: Thiopentone is the barbiturate on the ARTG; pentobarbital is not. Mannitol 20% (Osmitrol 100 g/500 mL) is on the ARTG. Use the local ICU protocol for hypertonic saline strength and volume. Call the state retrieval service for patients outside a neurosurgical centre.
EU: Same principles; SIBICC 2019 and NCS 2020 cerebral oedema guideline.
US: BTF 4th edition (2016) and SIBICC 2019; pentobarbital is the usual barbiturate.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Increased Intracranial Pressure Management?
The Increased Intracranial Pressure Management is a emergency clinical algorithm for Neurology. It provides a structured decision tree to guide clinical decision-making, based on Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC): management algorithm for patients with ICP monitoring (Hawryluk et al, Intensive Care Med 2019).
What guideline is the Increased Intracranial Pressure Management based on?
This algorithm is based on Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC): management algorithm for patients with ICP monitoring (Hawryluk et al, Intensive Care Med 2019) (DOI: 10.1007/s00134-019-05805-9).
What are the limitations of the Increased Intracranial Pressure Management?
Known limitations include: Adults only. Tiers are from severe TBI consensus (SIBICC 2019); other causes (stroke, ICH, tumour, liver failure) need cause-specific care; Hypertonic saline strength and volume, and barbiturate doses, follow the local ICU protocol; ICP monitoring and Tier 2-3 therapies need a neurosurgical ICU; Evidence for most ICP therapies is low quality or consensus. Individual patient factors may require deviation from these recommendations.
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