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 and Herniation

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In one line

·When the brain swells or a mass grows inside the hard skull, pressure climbs and squeezes the brainstem—the part that keeps you breathing and awake.

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Normal physiology

·Inside the skull sit three things: brain tissue (the squishy gray and white matter), blood (flowing through arteries and veins), and cerebrospinal fluid or CSF (clear liquid made by the choroid plexus in the brain's fluid chambers, called ventricles, that cushions the brain and washes away waste). The skull is a rigid bone box that cannot stretch. Normally these three volumes balance each other—if one goes up a little, another goes down a little—so pressure stays steady around 5 to 15 mm Hg. This balance is called the Monro-Kellie doctrine.

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What goes wrong

·Something adds extra volume inside the skull—a tumor, swelling (edema), a blood clot (hematoma), or blocked CSF drainage (hydrocephalus)—and the skull cannot stretch to make room. Pressure climbs. At first the body pushes out some CSF and blood to compensate, but once that safety margin runs out, pressure spikes fast. The rising pressure squeezes blood vessels, cutting oxygen delivery, and pushes the brain downward toward the only opening at the skull base, crushing the brainstem.

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Hallmark signs

·Headache that gets worse and worse
·Throwing up without feeling sick to the stomach first
·One pupil gets bigger than the other, or both pupils stop reacting to light
·Vision gets blurry or dims, sometimes seeing double
·Confusion, trouble staying awake, or falling into a coma
·Body suddenly gets stiff with arms bent inward or stretched out straight (posturing)
·Breathing becomes slow, irregular, or stops and starts in strange patterns
·Blood pressure shoots up while heart rate drops (Cushing's triad with abnormal breathing)

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Red flags · escalate now

·One pupil suddenly much bigger than the other or not reacting to light
·Stiff posturing (arms bent in tight or stretched out straight)
·Glasgow Coma Scale dropping (person less awake, less responsive)
·Cushing's triad: high blood pressure, slow heart rate, and abnormal breathing
·Sudden severe headache with projectile vomiting

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Workup

·Non-contrast head CT (computed tomography)
·Brain MRI with and without gadolinium contrast
·Serum sodium (Na⁺)
·Serum osmolality
·Arterial blood gas (ABG) with PaCO₂
·Intracranial pressure (ICP) monitor—intraventricular catheter or intraparenchymal bolt
·Complete blood count (CBC) and coagulation panel (PT, INR, aPTT, platelets)
·Lumbar puncture (LP) with opening pressure (only if no mass or herniation risk on imaging)

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Treatment

·Elevate the head of the bed to 30 degrees and keep the neck midline (straight, not turned)
·Hypertonic saline IV—3% continuous infusion or 23.4% bolus (30 mL over 10–20 minutes)
·Mannitol IV—0.25–1 g/kg bolus over 15 minutes
·Controlled hyperventilation—target PaCO₂ 30–35 mmHg
·External ventricular drain (EVD)—catheter placed into the lateral ventricle to drain CSF
·Surgical decompression—craniotomy (opening the skull) to remove mass (hematoma, tumor, bone fragment) or decompressive craniectomy (removing part of the skull to give the brain room to swell)
·Sedation and analgesia—propofol infusion (25–75 mcg/kg/min) or midazolam, plus fentanyl for pain

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NCLEX trap

·Sleepiness in increased ICP means the brainstem (the bottom part of the brain that controls breathing and waking) is being squeezed. You need to lower the pressure and find the cause — not put them to sleep. Sedatives hide the problem, slow breathing (which raises carbon dioxide and makes brain swelling worse), and make the pressure climb even higher.
·High blood pressure with increased ICP is the body protecting the brain — pushing harder to get blood through the squeeze. It is not the problem; it is the body's answer. Lowering it will cut off blood to the brain. Find and fix what is causing the increased ICP first. Only lower BP if it is dangerously high (systolic over 180–200) AND you are actively treating the ICP at the same time.
·Extra fluid adds volume inside the skull and makes increased ICP worse — like pumping more air into an already full balloon. Use hypertonic saline (extra-salty water, 3% or 23.4%) to pull fluid out of the brain tissue instead. Less fluid in the brain = lower pressure. Keep IV fluids at just enough to maintain blood pressure — not wide open.
·A blown pupil from herniation can get better if you lower the pressure fast and fix the cause. The oculomotor nerve (cranial nerve III, the nerve that moves the eye and shrinks the pupil) is squeezed, not dead. Act fast — this is a medical emergency, not a permanent injury. The sooner you relieve the pressure, the better the chance the nerve will recover.
·A dropping Glasgow Coma Scale in increased ICP means the brainstem is being crushed. This is an emergency. You need to raise the head of the bed to 30 degrees, lower pressure with hypertonic saline or mannitol (medicines that pull fluid out of the brain), prepare for surgery, and maybe put in an EVD (external ventricular drain, a tube that lets extra cerebrospinal fluid out of the skull). Oxygen alone will not fix increased ICP.
·Clinical signs — especially blown pupil, low alertness, slow heart rate with high blood pressure and irregular breathing (Cushing's triad) — mean herniation is happening now. Start treatment first while getting the scan. Do not wait. Brain damage happens in minutes. Treat the patient, not the scan.

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