Approach to the Critical Patient

Immediate stabilization

Airway and breathing priorities

Circulation and perfusion priorities

Herniation recognition and escalation

Herniation warning signs

Herniation protocol actions

Monitoring targets

ICP and CPP monitoring

Neuromonitoring bundle

Consult triggers

Neurosurgery

Neurology

Ophthalmology

History

Headache characterization

ICP headache features

Associated symptoms

Alarm features in history

Acute high-risk features

Subacute high-risk features

Etiology-specific history

Traumatic etiology

IIH history

Vascular history

Past medical and medication history

Relevant prior diagnoses

Family history

Physical Exam

Vital signs and general

Hemodynamic and vital sign assessment

Neurologic examination

Level of consciousness

Pupillary examination

Fundoscopy

Cranial nerve examination

Motor examination

Head and neck examination

Skull and scalp

Neck examination

PITFALLS

Examination pitfalls

Differential Diagnosis

Life-threatening causes

Intracranial hemorrhage

Mass lesions

Vascular causes

Cerebral venous sinus thrombosis

Inflammatory and infectious causes

Meningitis

Hydrocephalus

Non-structural causes

Idiopathic intracranial hypertension

Laboratory Tests

Core metabolic and hematologic panel

Complete blood count

Comprehensive metabolic panel

Coagulation studies

Osmolality and osmotherapy monitoring

Serum osmolality

Serum lactate

Arterial blood gas and ventilatory monitoring

Arterial blood gas

Infection and CSF analysis

Blood cultures

CSF analysis post-LP

ESR and CRP

Toxicology

Diagnostic Tests

Scoring Systems

ICP-related scoring systems

IIH diagnostic criteria (revised Friedman criteria)

Monro-Kellie doctrine

MRI

MRI brain with contrast

MRV (MR venography)

CT

Non-contrast CT head

CT angiography

CT with contrast

Ultrasound

Optic nerve sheath diameter (ONSD)

Transcranial Doppler (TCD)

FAST and extended FAST

Disposition

ICU admission criteria

ICU-level care triggers

Neurosurgery consultation triggers

Step-down and floor admission

Intermediate care criteria

Discharge criteria

Discharge appropriate if all met

Transfer criteria

Treatment

Immediate first-tier interventions

Head positioning

Hyperosmolar therapy

CSF drainage

Ventilatory management

Controlled ventilation targets

Sedation and analgesia

Sedation protocol

Neuromuscular blockade

Second-tier therapies

Barbiturate therapy

Therapeutic hypothermia

Cause-specific treatments

Vasogenic edema (tumor, abscess)

Idiopathic intracranial hypertension

Cerebral venous thrombosis

Seizure prophylaxis

Surgical interventions

Decompressive craniectomy

Mass lesion evacuation

Special Populations

Pregnancy

Physiologic considerations in pregnancy

IIH in pregnancy

Imaging considerations

Drug safety in pregnancy

Cerebral venous thrombosis post-partum

Geriatric

Age-related physiologic changes

Fall risk and hemorrhage patterns

Medication considerations

Frailty and goals of care

Pediatrics

Age-specific normal ICP values

Clinical presentation differences

Pediatric TBI considerations

Pediatric IIH

Hydrocephalus in children

Background

Epidemiology

Incidence and prevalence

Mortality and morbidity by etiology

Pathophysiology

Monro-Kellie doctrine and compensatory mechanisms

Cerebral autoregulation

Cerebral edema types

Herniation syndromes

Therapeutic Considerations

Evidence base for osmotherapy

ICP monitoring evidence

Medications that elevate ICP (to avoid or discontinue)

Emerging and adjunctive therapies

Patient Discharge Instructions

copy discharge instructions

Discharge instructions for increased intracranial pressure

Return to emergency immediately if

References

Guidelines and key sources

Brain Trauma Foundation guidelines

Key clinical trials and systematic reviews

Diagnostic and non-invasive monitoring

IIH and special topics