Stepladder Management of Increased ICP (ENLS Protocol)

First question to ask in ICP management should be “Does this patient need urgent decompressive hemicraniectomy?”  If ICP crises is progressing rapidly, a neurosurgeon should be consulted urgently to discuss the risks and benefits of surgery.  ICP can be lowered by craniectomy alone (15% decrease) or by craniectomy and dural opening (70% decrease).  Surgical decompression has been shown to improve brain tissue oxgenation, survival in malignant MCA infarction, but does not improve outcomes in TBI.



The Neurocritical Society published guidelines on the management of intracranial hypertension and herniation in 2012.  A summary of the four tiers in the stepwise treatment of ICP crises is listed below.

ENLS ICP Treatment Tiers

Tier Zero:

  • HOB > 30 degrees
  • ensure adequate sedation
  • correct hyponatremia, hyperthermia, and vasogenic edema
  • keep CPP > 60-70 mm Hg
  • **normocarbia (PaCO2 35-45)
  • **good oxygenation (PaO2 >100)

Tier One:

  • secure airway
  • mannitol 0.5-1 gm/kg IV bolus
  • start 3% saline 10-20 cc/hr
  • CSF drainage

Tier Two:

  • hypertonic saline bolus (3%-23.4%)
  • consider propofol bolus and infusion
  • consider decompressive craniotomy

Tier Three:

  • pentobarbital bolus and infusion titrated for ICP goal
  • induce hypothermia
  • hyperventilation if used with cerebral oxygen monitor
  • raise MAP to improve CPP



  1. achieve normothermia by:
    • acetaminophen 325-650 PO or PR q6h
    • ibuprofen 500mg PO q6h
    • surface cooling – ice packs, cool blankets, surface devices (Arctic Sun)
    • intravascular cooling – catheter inserted into IVC that cools blood, effective and quick but increases risk of venous thrombosis and infection
  2. hyperventilation – effective but lasts only 10-20 hours, CO2 levels <25 can increase risk of brain ischemia, sustained hyperventilation x 5 days has been shown to slow recovery of severe TBI at 3 and 6 months
  3. Mannitol – target osmolality to 300-320, dose is 025 to 1.5 g/Kg bolus IV, watch out for hypotension, hypovolemia and renal tubular damage
  4. barbiturates – pentobarbital most commonly used (that is, if barbiturates are used at all), load with 5-20mg/Kg bolus then 1-4mg/Kg/hr infusion; watch out for hypotension; will lose neurologic exam so requires accurate monitoring to guide therapy – EEG, ICP, hemodynamics



See link below for MS Word / PDF document of sample order sheet for management of ICP crisis.

ICP Crisis Order Sheet

ICP Crisis Order Sheet (Sy, MD)


Miller, Chad M, and Michel T Torbey. Neurocritical Care Monitoring. Print.

Stevens, Robert D., Michael Shoykhet, and Rhonda Cadena. “Emergency Neurological Life Support: Intracranial Hypertension And Herniation”. Neurocritical Care 23.S2 (2015): 76-82. Web.

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