ICU Map
neurologic

Raised ICP / Impending Herniation

Rapid neurologic deterioration with suspected intracranial hypertension requiring immediate physiologic stabilization, hyperosmolar rescue and urgent definitive neuroimaging/neurosurgical treatment.

CLINICAL ALGORITHMMedically Verified (2026-09-15)

Neurologic deterioration with suspected intracranial hypertension or impending herniation

Figure: Neurologic deterioration with suspected intracranial hypertension or impending herniation. This action-focused visual summarizes the linked Clinical Problem; the full problem text, evidence references and local policy remain the source of truth.(Action pathway — use the full evidence-linked problem and local protocol for clinical decisions)

Recognize

  • Treat rapidly falling consciousness, new anisocoria/fixed pupil, extensor posturing, unexplained bradycardia/hypertension, recurrent vomiting or acute focal deterioration in a patient with brain injury as possible intracranial hypertension/herniation until proven otherwise.

Immediate positioning / physiology

  • Elevate the head about 30 degrees, keep the head and neck midline and avoid venous outflow obstruction. Prevent hypoxemia and hypotension, correct severe hypercapnia, treat fever and seizures, and avoid unnecessary stimulation while arranging urgent CT/neurosurgical assessment.

Hyperosmolar rescue

  • For clinical herniation or acute ICP crisis, give hypertonic saline or mannitol using a protocol appropriate to the diagnosis, blood pressure, sodium/osmolality, renal function and volume status. Hypertonic saline is often favored when hypotension or hypovolemia makes mannitol-induced diuresis undesirable.

Ventilation

Definitive treatment

Reassess

Caution

Hyperventilation and hyperosmolar therapy are bridges, not definitive treatment. A patient with signs of herniation needs the cause identified and reversed urgently.

Direct evidence for this problem

2 sources
guideline•2020
Guidelines for the Acute Treatment of Cerebral Edema in Neurocritical Care Patients ↗

Neurocritical Care Society guidance for acute cerebral edema and hyperosmolar therapy.

guideline•2016
Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition ↗

Foundational severe-TBI intracranial-pressure and cerebral-perfusion management guidance.

Evidence status

Review metadata not yet recorded.

Status, review dates and guideline versions appear here once editorial metadata is authored for this content.

Actionable Clinical Workflows (4)

Step-by-step ICU Processes
ICU Sedation Titration & ABCDEF Liberation

From 'analgesia-first' multimodal pain control and light sedation targeting to daily SAT/SBT coordination, delirium screening, and early mobility.

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Acute Neurologic Deterioration & Brain Death Workflow

From acute GCS drop and herniation emergency measures to emergent CT, neurocritical intervention, and death by neurologic criteria determination.

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Status Epilepticus Emergency Management

From emergent first-line benzodiazepine administration to second-line IV non-sedating AEDs and continuous cEEG anesthetic burst suppression.

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Altered Consciousness

From securing the basics to categorizing structural, toxic-metabolic, infectious, and seizure-related causes.

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Deep-Dive Topic Destinations (3)

Reference Knowledge
Intracranial Hypertension & Cerebral Edemaneurology

Monro-Kellie doctrine, ICP waveforms (P2>P1, Lundberg A-waves), CPP targets (60–70 mmHg), herniation syndromes, and the 4-tier BTF management protocol.

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Altered Consciousness, Coma, & Delirium in the ICUneurology

ARAS neuroanatomy, structural vs toxic-metabolic coma, the comprehensive Coma Exam (pupils, cold calorics, posturing), FOUR score, and CAM-ICU delirium.

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Status Epilepticusneurology

Recognition and time-sensitive escalation of care for prolonged or repeated seizures.

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