Compare conditions

Put any two — or three — conditions side by side, adult or pediatric, to spot the look-alike differences fast, row by row.

Increased ICP (pressure in brain)

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In one line

·The skull is a closed box — nothing can expand inside without crushing something else.

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Normal physiology

·The brain lives inside a rigid skull that cannot stretch. Inside are three things that share the space: brain tissue, blood in arteries and veins, and cerebrospinal fluid (CSF) made by the choroid plexus in the brain's hollow chambers (ventricles). CSF flows from the ventricles through narrow channels, around the brain and spinal cord in the subarachnoid space, and drains into veins through one-way valves called arachnoid granulations. Blood flows in through arteries and out through veins. Pressure inside the skull (intracranial pressure, or ICP) normally stays between 5 and 15 mmHg — low and steady.

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What goes wrong

·Something takes up extra space inside the closed skull, and pressure climbs. The causes fall into four groups: a mass (tumor, blood clot, abscess), brain swelling (from stroke, trauma, liver failure, or infection), blocked CSF flow (hydrocephalus), or backed-up venous blood (clot in a big vein or jugular compression). At first the body squeezes out CSF and venous blood to make room. Once that buffer runs out, ICP shoots up fast. High ICP squeezes blood vessels, starving the brain, and pushes brain tissue toward openings in the skull (herniation). The brainstem — which controls breathing, heart rate, and wakefulness — sits right above the biggest opening (foramen magnum), so it gets crushed first.

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Hallmark signs

·Headache that gets worse when lying down or in the morning
·Throwing up without feeling sick to the stomach first (projectile vomiting)
·Blurry vision or brief moments when vision goes dark (visual obscurations)
·Feeling confused, sleepy, or hard to wake up
·One pupil becomes larger than the other or stops shrinking in bright light
·Seizures
·Cushing triad: high blood pressure, slow heart rate, and irregular breathing
·Stiff neck or being forced into an arched-back position (opisthotonus)

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Red flags · escalate now

·Confusion, extreme sleepiness, or impossible to wake up
·One pupil much larger than the other or not reacting to light
·Sudden seizure
·Cushing triad: very high blood pressure, slow pulse, and weird breathing pattern
·Sudden severe headache described as 'the worst of my life'

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Workup

·Non-contrast head CT (computed tomography scan)
·Intracranial pressure (ICP) monitor — intraventricular catheter or intraparenchymal bolt
·Cerebral blood flow (perfusion) pressure (CPP) calculation — MAP minus ICP
·Serum sodium and serum osmolality
·Arterial blood gas (ABG) — specifically PaCO2
·Fundoscopic exam (looking at the back of the eye with an ophthalmoscope)

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Treatment

·Head of bed elevated 30 degrees, neck midline and straight
·Hypertonic saline (3% continuous infusion or 23.4% bolus) or mannitol 0.25–1 g/kg IV
·Sedation and analgesia — propofol infusion, fentanyl boluses
·Controlled hyperventilation to PaCO2 30–35 mmHg
·Drain cerebrospinal fluid via external ventricular drain (EVD)
·Decompressive craniectomy (removing part of the skull)
·Definitive source control — evacuate a pooled collection of blood (hematoma), resect tumor, shunt hydrocephalus

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NCLEX trap

·Normal pupils early on do NOT mean the patient is safe. Herniation moves fast — a pupil can blow (get stuck wide open) in minutes to hours. Watch the trend, not just one snapshot. A pupil that is slowly getting bigger over time is more dangerous than one that has always been big. Never wait if other warning signs are present (worsening sleepiness, vomiting, high blood pressure with slow heart rate).
·Sedation and pain control CAN help lower ICP by calming the brain's activity — but ONLY after you secure the airway and figure out what is wrong. If you sedate someone before protecting their breathing (usually by intubation), their airway can collapse and their brain gets starved of oxygen, making everything worse. The order is: airway first, THEN sedation, THEN find and fix the cause.
·That high blood pressure is the Cushing reflex — the body's last-ditch effort to push blood into a squeezed brain. If you lower the blood pressure, you cut off the brain's only lifeline and make herniation worse. Leave the blood pressure alone. Fix the increased ICP itself (drain the fluid, remove the mass, or make more room by removing part of the skull). The blood pressure will drop naturally once the pressure inside the skull comes down.
·A new, severe headache CAN mean increased ICP, but it can also mean a brain bleed, meningitis (infection of the brain's lining), or even a stroke. Do not just treat the symptom — find the cause. Get a CT scan. Call the doctor. A headache is a warning light on the dashboard, not the actual broken part. Sending the patient home without imaging can miss a life-threatening problem.
·Fast breathing does lower CO₂, which makes brain blood vessels squeeze tight and shrinks brain blood volume a tiny bit — but this only buys you about 15 minutes, and if you do it too long the brain can swell worse afterward (rebound swelling). Use hyperventilation ONLY as an emergency bridge while you prepare for the real fix: surgery to drain fluid, remove a mass, or take off part of the skull to make room. It is NOT a cure.
·A blown pupil means herniation is happening RIGHT NOW — the brain is being shoved down and crushing the third cranial nerve (the nerve that shrinks the pupil) and the brainstem. This is a neurosurgical emergency. The patient needs emergency surgery (remove part of the skull, drain the fluid, or take out the mass) in MINUTES, not hours. Medicine alone will NOT stop herniation. Without immediate surgery, the brainstem gets crushed and the patient dies or stays in a permanent coma.

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