Raised intracranial pressure

Manage now— do this, in order

• Tier 0 costs nothing and works within seconds: head-up at 30° (not beyond — that lowers CPP), head in the midline, neck completely free — remove tight collars, tube ties and tracheostomy tape; turn the whole patient, never the head alone.
• Treat fever — euthermia is mandatory: paracetamol 1 g IV/PO/PR 6-hourly (max 4 g/day; child 15 mg/kg 6-hourly, max 60 mg/kg/day) with surface cooling. Treat pain and agitation, suppress cough and straining, give an antiemetic, catheterise, relieve constipation, and keep glucose roughly 6-10 mmol/L, never below 4.
• Stop seizures, which double cerebral metabolic rate: lorazepam 4 mg IV (child 0.1 mg/kg, max 4 mg), diazepam 5-10 mg IV, or buccal midazolam 10 mg (child 0.3 mg/kg) without access; then phenytoin 20 mg/kg IV at no more than 50 mg/min with cardiac monitoring, or levetiracetam 60 mg/kg (max 4.5 g).Doctor / Nurse
• Intubate and ventilate for GCS 8 or less, a falling GCS, absent airway reflexes or inadequate respiratory effort — with smooth, deep induction, since laryngoscopy raises ICP. Ventilation targets: SpO2 above 94% and PaCO2 4.5-5.0 kPa (35-38 mmHg) — normocapnia, not hyperventilation, as the routine target.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.
• Isotonic fluid only, aiming for euvolaemia with a high-normal blood pressure and vasopressor support to hold CPP at least 60 mmHg once volume-replete. Never hypotonic fluid — free water worsens oedema. Do not dehydrate either: a single episode of hypotension or hypoxia measurably worsens outcome. And never treat the hypertension of the Cushing response — if pressure must be lowered for another reason use labetalol or nicardipine, never nitroprusside.Doctor / Nurse
• Osmotherapy for a new dilating or fixed pupil, a fall of 2 or more GCS points, posturing, the Cushing response, or imaging showing mass effect — immediately, without waiting for imaging, in active herniation: mannitol 20% 0.5-1 g/kg IV over 15-20 minutes (child 0.5-1 g/kg, repeat 0.25-0.5 g/kg) into a large vein through a filtered giving set, catheterise, keep osmolality below 320 mosmol/kg, replace the diuresis; or hypertonic saline 3% 3-5 mL/kg over 10-20 minutes — prefer it if hypotensive, hypovolaemic, oliguric or renally impaired; 23.4% saline 30 mL bolus only via central access.Doctor / Nurse
• Controlled hyperventilation is the emergency brake, not a treatment: PaCO2 4.0-4.7 kPa (30-35 mmHg) and no lower, in an intubated sedated patient, guided by blood gas or capnography, only as a bridge of minutes to an hour — wean slowly, because abrupt discontinuation causes rebound intracranial hypertension. Never blindly or vigorously bag-ventilate "to blow off the CO2".Doctor / NurseNot available at your setup — Arterial blood gas.
• Corticosteroids only for vasogenic oedema around a tumour or abscess: dexamethasone 10-20 mg IV bolus then 4 mg every 6 hours for herniation from a mass lesion (paediatric 0.25-0.5 mg/kg then 0.25 mg/kg 6-hourly), with gastric protection and glucose monitoring. Never in traumatic brain injury (increased mortality on randomised evidence), ischaemic stroke or intracerebral haemorrhage.Doctor / Nurse
• Treat the cause — every medical measure is temporising: evacuate the clot, drain the CSF (a ventricular drain is more effective than any drug when hydrocephalus is present; in a shunted patient palpate the reservoir and arrange a shunt tap or revision), remove the mass, correct the sodium — and in suspected bacterial meningitis give ceftriaxone 2 g IV 12-hourly immediately (child 75-100 mg/kg/day, max 4 g/day). Without a monitor the patient is the monitor: itemised GCS, pupils, limb power, BP, heart rate, respiratory pattern and temperature at short fixed intervals.Doctor / Nurse