TBI & the one thing that kills them: rising intracranial pressure
NG-247NEURO · TRAUMAADHD-friendly visual edition
Almost nothing on this page is about the blow to the head. It is about what happens
in the hours afterwards, inside a skull that cannot get any bigger. Blood collects, brain
swells, and pressure climbs until the brain is squeezed out of the only hole it has. Your whole job is to
spot that early — and the earliest, most sensitive sign is not a vital sign at all. It is a
change in level of consciousness.
📦 Closed boxBrain + blood + CSF in a rigid skull. Add anything and something else must be pushed OUT — that is the Monro–Kellie principle.
⭐ LOC changes FIRSTRestless, irritable, confused, harder to rouse. Earliest & most sensitive sign of ↑ ICP. Report a GCS drop of even 1 point.
🚨 Cushing’s triad = LATE↑ systolic with widening pulse pressure · bradycardia · irregular respirations. This is herniation, not a warning.
💧 Clear drainage = priorityEar or nose = basilar skull fracture. Check it for glucose / halo ring. ❌ Never pack it, never insert an NG tube.
🧠
WHAT ACTUALLY HAPPENED
STEP 1 · CAUSE
A head injury is two injuries: the damage from the impact itself, and the swelling that follows it. You cannot undo the first. Your entire job is the second.
📦 The whole page in one picture — the skull is a closed box
Brain (~80%) + blood (~10%) + CSF (~10%) live inside a rigid box that cannot expand.
If a clot takes up space, the body buys time by squeezing CSF down into the spinal canal and pushing
venous blood out. That is why a patient can look fine while a bleed is growing — compensation
is working. When it runs out, pressure rises almost vertically.
Normal intracranial pressure in an adult is 5–15 mmHg. Sustained pressure above roughly 20–22 mmHg is treated.
🧠 “Three tenants, one apartment.” Brain, Blood, CSF share a flat with no extra rooms. A new tenant (a clot) means someone gets evicted — and when nobody is left to evict, the walls start pushing back.
🧨 How heads get hurt
Motor vehicle collisions — the classic adult mechanism
Falls — especially > 20 ft, and any fall in the elderly or anticoagulated
Injury is local before it is global. Match the symptom to the map and you can name the lobe on an exam question without memorizing a list.
🧠 Front OFFICE · Purr-ietal · TEMPO · Ocular · cere-BaLance · brain STEM runs the engine.
🔁 Coup–contrecoup: one blow, two bruises
The brain floats in CSF. When the skull suddenly stops, the brain keeps traveling, hits the inner
skull at the point of impact (coup), then rebounds and strikes the opposite side
(contrecoup). The two most commonly bruised areas end up being the frontal and
occipital lobes.
So the expected deficits are the frontal-lobe ones — memory, speech, judgment, movement — plus
the occipital one, visual perception.
🧠 “Coup = the hit. Contrecoup = the bounce.” Ask a coup–contrecoup question and the answer is almost always memory, speech and vision.
💥 Concussion — a mild TBI, not “nothing”
A transient disturbance of brain function from an impact. There may be a brief loss of
consciousness or none at all. Imaging is usually normal — that does not make it harmless.
Headache, dizziness, nausea
Amnesia around the event (before and/or after)
Feeling “foggy”, slowed thinking, irritability
Light and noise sensitivity, sleep changes
🧠 Second impact before the first has healed is the dangerous one — that is why athletes must be cleared before returning.
🩹 Contusion & diffuse axonal injury
Contusion = an actual bruise of brain tissue — it swells and bleeds over hours, so the patient
often gets worse on day 1–3, not better.
Diffuse axonal injury (DAI) = shearing of nerve fibers from rotational force. CT can look
almost normal while the patient is deeply comatose. Prognosis is poor.
🧠 “Normal CT + deep coma = think DAI.”
🖼️ Imaging — what and when
Non-contrast CT head is the FIRST study — fast, and it shows acute blood, swelling and fracture
MRI — better for small/older lesions and DAI, but slower; not the emergency test
C-spine imaging — assume a cervical injury with any significant head trauma until cleared
SEE ALSO Base neuroanatomy, the cranial nerves and the full neuro assessment framework live on NG-255 · Neuro Overview.
🧠 CT first, always. “Bleeding? Get a CT” — you cannot treat what you have not localized.
📈
RISING ICP — EARLY vs LATE
STEP 2 · CLUES
This is the highest-yield section on the page. Exams live on the difference between the sign that appears FIRST and the sign that appears LAST.
⭐ The single most important sentence on this page
A change in level of consciousness is the EARLIEST and most sensitive sign of rising ICP.
Not the blood pressure. Not the pulse. Not the pupils. Restlessness, irritability, agitation,
confusion, and “just not quite right” come first — often hours before a single vital sign moves.
A patient who was oriented ×4 and is now slightly confused has changed, and that change is the finding.
🧠 “The brain talks before the vitals do.” If a question offers you “restless and irritable” alongside a normal BP and HR, restless-and-irritable is the answer.
📈 The whole time-course on one graph
Read left to right. LOC changes at the far left; Cushing’s triad only appears at the far right, when herniation is already under way.
🧠 “LOC first, vitals last.” By the time the vital signs are abnormal, you have lost your head start.
🟢 EARLY signs — catch it here
↓ LOC: restless → irritable → agitated → confused → drowsy → hard to rouse
Severe headache, worse in the morning or on lying flat
Vomiting, often projectile and without nausea
Pupils becoming sluggish to light
Any new focal weakness or drift on one side
Blurred or double vision
A drop of even 1 point on the GCS
GCS Full Glasgow Coma Scale breakdown (eyes 4 · verbal 5 · motor 6, total 3–15) is on NG-255 · Neuro Overview.
🧠 “Grumpy before groggy.” Personality change comes before sleepiness.
🚨 LATE signs — you are already behind
CUSHING’S TRIAD (below) — the classic late trio
Unilateral fixed, dilated “blown” pupil on the same side as the lesion
Posturing: decorticate (arms flexed to the core) → decerebrate (arms extended, worse)
Coma, GCS ≤ 8
Loss of gag / corneal reflexes
Hyperthermia from hypothalamic damage
🧠 deCORticate = arms to the CORE. deCEREbrate = arms E-x-tended and it is Extremely bad. Flexion → extension is deterioration.
🚨 CUSHING’S TRIAD — say the direction of each one correctly
Component
Direction
What you actually see
Blood pressure
Systolic ↑, diastolic flat or ↓ → WIDENING PULSE PRESSURE
120/80 → 182/64. The body cranks systolic pressure to force blood past the pressure inside the skull.
Heart rate
↓ BRADYCARDIA
Baroreceptors answer the surge in systolic pressure by slowing the heart. < 60, often bounding.
Respirations
Irregular (and usually slow)
Cheyne–Stokes, apnoeic pauses, ataxic breathing — the brainstem is being crushed.
Cushing’s triad is a LATE, ominous sign of impending herniation — it is not an early warning and you never wait for it.
🧠 “HIGH pressure, LOW and SLOW everything else.” BP up · pulse down · breathing ragged. Two down, one up — and if a question’s answer choices all have tachycardia, none of them is Cushing’s.
💀 Herniation and the blown pupil
When compensation fails, the brain has only one direction to move: across the midline and then
downward. The medial temporal lobe slips over the tentorium and pins cranial nerve III, which
carries the fibers that constrict the pupil. Lose CN III and the pupil dilates and stops reacting.
🧠 “Blown pupil = blown side.” The dilated pupil is on the same side as the clot. New unequal pupils is a call-now finding, not a chart-and-recheck finding.
🧮 CPP — why blood pressure matters so much
CPP = MAP − ICP
Cerebral perfusion pressure is what actually drives blood into the brain. Normal is roughly
60–100 mmHg; the usual goal after TBI is to keep it > 60.
That gives you two ways to starve a brain: let ICP climb, or let the blood pressure fall.
Hypotension after head injury is devastating — a single episode worsens outcome.
🧠 “Pressure IN minus pressure ON.” Push MAP up or bring ICP down — both raise CPP.
🧠 EPIdural = EPIC and fast (artery, lens/lemon). SUBdural = SUBtle and slow (vein, crescent/banana).
🚨 EPIDURAL — the lucid interval
Between the skull and the dura, usually from a torn middle meningeal artery under a
temporal bone fracture. Arterial pressure means it fills fast.
The classic story: knocked out briefly → wakes up and talks normally
(LUCID INTERVAL) → deteriorates rapidly over minutes to hours.
Never leave — or discharge — a head-injured patient who lost consciousness and then “woke up fine.” That is the textbook epidural.
🧠 “Talk and die.” The lucid interval is the most-tested sentence about epidural hematoma. Surgical evacuation is the treatment and it is time-critical.
🩸 SUBDURAL — the slow one
Between the dura and the arachnoid, from torn bridging veins. Venous pressure is low, so
it oozes.
Acute — within 48 h, looks like a severe injury
Subacute — 2–14 days
Chronic — > 2 weeks; often a trivial bump that was forgotten
Highest risk: older adults (brain atrophy stretches the bridging veins), alcohol use,
and anyone on anticoagulants or antiplatelets.
🧠 The “new confusion” in an older adult weeks after a fall is a chronic subdural until proven otherwise.
🩸 SUBARACHNOID — the thunderclap
Blood under the arachnoid, in the CSF space. Traumatic after injury, or spontaneous from a
ruptured berry aneurysm.
Classic complaint: “the worst headache of my life,” sudden and maximal at onset, often with
nuchal rigidity and photophobia — because blood in the CSF irritates the meninges exactly the way
infection does.
LOOKS LIKE Stiff neck + headache + photophobia also describes NG-252 · Meningitis. Trauma or thunderclap onset points to blood; fever points to infection.
🧠 “Worst headache of my life” = subarachnoid until a CT says otherwise.
🧭 Tell them apart in one table
Epidural
Subdural
Subarachnoid
Layer
Skull ↔ dura
Dura ↔ arachnoid
Arachnoid ↔ pia (in the CSF)
Vessel
Artery (middle meningeal)
Bridging veins
Aneurysm / trauma
CT shape
Lens / lemon (biconvex)
Crescent / banana
Blood tracking in the sulci
Speed
Minutes–hours
Hours–weeks
Instant
Signature
Lucid interval
Slow confusion, elderly
Worst headache of my life
🧠 Lemon on top, banana below. The fruit shape gives you the layer, the layer gives you the vessel, the vessel gives you the speed.
💧 BASILAR SKULL FRACTURE — clear drainage is a priority finding
A fracture through the base of the skull tears the dura, so CSF leaks out through the nose or
ear. That means the sterile space around the brain now connects to the outside world.
Testing the drainage: CSF is positive for glucose (nasal mucus is not), and a drop on
gauze separates into a central blood spot with a clear halo ring.
Never pack the ear or nose · never insert a nasogastric tube or nasal suction catheter · never blow the nose. Use an ORO-gastric tube instead.
🧠 “Raccoon eyes, Battle’s behind the ear, halo on the gauze — nothing goes UP the nose.” A nasal tube can pass straight through the fracture into the brain.
✅ Which patient do you see FIRST?
Multi-car collision, several arrivals. The one with clear fluid draining from the right ear
goes first — that is an open head injury with an active route for infection and a high-energy
basilar fracture behind it.
Same logic for the patient whose GCS was 15 two hours ago and is 14 now: report to the provider
immediately. A falling GCS is a deteriorating brain.
🧠 Changing beats abnormal. A stable abnormal number is less urgent than a number that just moved.
🩺
NURSING CARE — LOWER THE PRESSURE
STEP 4 · CARE
Airway and oxygen first, then everything you do is aimed at one number: get ICP down and keep perfusion up.
✅ Positioning — the free intervention that actually works
🧠 “Head up, head straight, hips loose.” Three words, and you have the whole positioning answer.
🚨 Priority order at the bedside
1
Airway & oxygenation. Hypoxia and high CO₂ both raise ICP. GCS ≤ 8 generally means intubate.
Neuro checks + GCS on a schedule, and compare to the LAST set, not to “normal”.
4
Position and environment — HOB 30°, midline, quiet, dim, minimal stimulation.
5
Report any change in LOC, pupils, motor response or vitals immediately.
🧠 ABC still wins. A perfect neuro assessment on an obstructed airway is a failed answer.
❌ Do NOT cluster care
Each stimulating activity bumps ICP a little. Stack them together — suction, then turn, then bathe, then
family at the bedside — and the bumps add up into a spike the brain cannot buffer.
Space activities out; let ICP settle in between
Suction only when indicated: pre-oxygenate, keep each pass ≤ 10 seconds, limit the number of passes
Never nasotracheal suction if a basilar fracture is suspected
Quiet, dim room · limit visitors · avoid startling the patient
Never routinely suction a patient with raised ICP “to keep them clear” — suction is a trigger, not a routine.
🧠 “One thing at a time.” Cluster care is correct for a preemie and wrong for a raised-ICP brain.
🚫 Stop the straining
Stool softeners — straining at stool is a textbook ICP spike
Antiemetics — vomiting spikes ICP hard
Antitussives for a cough
No isometric exercises, no pushing against the bed to move up
Teach the patient to exhale while being repositioned rather than hold their breath
🧠 Valsalva is the enemy. Anything you would strain for — pooping, vomiting, coughing, pushing — sends pressure straight to the head.
💧 Fluids — isotonic only
Give isotonic fluid (0.9% NaCl) to keep the blood pressure and CPP up.
Never hang hypotonic fluid — D5W or 0.45% NaCl — in a patient with cerebral edema. Free water follows the osmotic gradient straight into brain cells and makes the swelling worse.
Watch intake and output closely; both diabetes insipidus and SIADH occur after brain injury.
SEE ALSONG-282 · SIADH vs DI — both are classic post-neurosurgical complications.
🧠 “Hypotonic = swollen brain.” D5W is essentially free water once the dextrose is metabolized.
💊 Drugs used to bring ICP down
Mannitol — osmotic diuretic; pulls water out of brain tissue. Monitor serum osmolality, electrolytes, urine output and BP; use a filter needle and check for crystals. Watch for dehydration and a falling BP.
Hypertonic saline (e.g. 3%) — pulls fluid out of the brain and supports blood pressure. Monitor sodium closely; usually a central line.
Antiseizure medication — seizures spike ICP; prophylaxis is common early after severe TBI.
Analgesia / sedation — pain and agitation raise ICP, but must be titrated so neuro checks are still possible.
Not routine: corticosteroids are not used for traumatic brain edema (they are used for edema around tumors).
🧠 Mannitol = “man, I need a Foley.” Big diuresis — expect a urinary catheter, hourly outputs and a close eye on the BP.
🔧 Advanced measures you may see
ICP monitoring / external ventricular drain (EVD) — measures pressure and can drain CSF. The transducer is leveled at the tragus / foramen of Monro; re-level after any bed change.
Ventilation targets — keep CO₂ in the normal range (35–45 mmHg). Aggressive hyperventilation constricts cerebral vessels and is only a brief rescue, not a therapy.
Decompressive craniectomy — remove part of the skull so the brain has room; the box stops being closed.
Surgical evacuation of an epidural or large subdural hematoma.
🧠 An EVD that is left open when it should be clamped drains too much CSF. Always know whether your drain is open or clamped before you move the patient.
✅ Also on your list
C-spine precautions until the cervical spine is cleared — log-roll, collar stays on
Seizure precautions at the bedside (padded rails, suction and oxygen ready)
Nutrition early — TBI is hypermetabolic
DVT and skin prophylaxis, eye care if the blink reflex is gone
Family teaching — talk to the patient, keep stimulation low, expect emotional lability
SEE ALSO Everything about the seizure itself is on NG-226 · Seizures.
🧠 Every head injury is a neck injury until imaging says it isn’t.
🏠
DISCHARGE TEACHING
STEP 5 · TEACH
Most head injuries go home. The teaching is what keeps the ones that are still bleeding from dying on the sofa.
⭐ Come back IMMEDIATELY if…
🚶Difficulty walkingataxia — a classic return sign
🤮Repeated vomitingespecially projectile
🤕Worsening headachenot relieved by rest
👁️Unequal pupilsor blurred/double vision
😵Confusion or drowsinessharder and harder to wake
💧Clear drainagefrom nose or ear
⚡Seizureany activity at all
🗣️Slurred speechor new weakness
🧠 “Walk, Wake, Watch the pupils.” Ataxia, worsening drowsiness and a new unequal pupil are the three that must not wait until morning.
✅ A responsible adult stays with them
Someone must be with the patient for the first 24 hours and able to check on them — because the
dangerous change is a change in how rousable they are, and that needs an observer.
Teach the observer exactly what to look for and to call emergency services rather than drive in if the
patient cannot be woken.
🧠 The patient cannot monitor their own level of consciousness. That is the whole reason someone has to stay.
😴 They do NOT have to stay awake all night
This is the classic myth. Sleep is fine and is part of recovery. What matters is that the adult
with them can wake them when they try — waking periodically to check rousability is the point,
not sleep deprivation.
🧠 “Wake-able, not awake.” If a question offers “keep the patient awake all night”, it is wrong.
❌ No alcohol
Alcohol vasodilates — including cerebral vessels — which increases intracranial blood volume and
makes swelling worse. It also masks the exact symptoms you told them to watch for: drowsiness, confusion,
unsteady walking and vomiting.
Also avoid sedatives and sleeping tablets for the same reason, and check with the provider before
taking NSAIDs or aspirin because of bleeding risk.
🧠 Alcohol both widens the vessels and hides the warning signs. Two reasons, one rule.
🧘 Recovery is a gradual ramp
Rest first, then gradually increase activity as symptoms allow
Limit screens, loud noise and bright light while symptoms persist
No return to sport or contact activity until formally cleared
Expect irritability, poor concentration and fatigue for days to weeks — warn the family so it isn’t read as personality change
Do not drive until cleared
🧠 Second impact syndrome: a second hit before the first concussion has healed can cause catastrophic swelling. That is why clearance is non-negotiable.
🎯 NCLEX traps on this topic
The stem says…
The answer is…
“Clear nasal drainage after head trauma”
Check the drainage for glucose (and halo sign) — suspect basilar skull fracture
“Which patient do you see first after a multi-car collision?”
The one with clear fluid draining from the ear
“GCS was 15, now 14 — first action?”
Report to the provider immediately
“Client in C-spine collar after a fall — priority assessment?”
Obtain a Glasgow Coma Scale score
“Most likely affected by coup–contrecoup?”
Memory, speech and vision (frontal + occipital)
“Expected finding with occipital lobe injury?”
Deficits in visual perception
“Passed out, woke up, now drowsy again”
Epidural hematoma — lucid interval; stay with the patient, escalate
“BP 182/64, HR 48, irregular respirations”
Cushing’s triad — LATE sign of ↑ ICP; notify immediately
🧠 If the option is “report / notify now” and the finding is a NEW neuro change, that is almost always the answer.
📦 Closed boxBrain + blood + CSF. Compensation buys time by moving CSF and venous blood out — then pressure climbs vertically.
⭐ LOC = first · Cushing’s = lastRestless/irritable/confused is the earliest sign. ↑ systolic with widening pulse pressure + bradycardia + irregular RR is LATE.