Question 5

Describe a tiered strategy for the management of raised intracranial pressure in traumatic brain injury, including when each treatment should be considered. (100% marks)

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College answer

Aim: To outline the process of management of raised ICP.

Key sources include: Paper 2015.1 q12, BTF guidelines. CanMEDS Medical Expert. Discussion: This is a repeat SAQ with an extension asking the candidate to nominate a tiered strategy and give an opinion on timing and implementation of each strategy for control of ICP. Most candidates had the basics of knowledge. Those candidates who did well were well organised, familiar with the guidelines for a tiered approach and provided specifics around timing and ICP levels for intervention and progression of interventions. Details for therapies such as osmotherapy targets and temperature targets were also a component of the better answers. The vast majority did well, and these candidates should be commended


Question 12 from the first paper of 2015 is in fact a question about a patient with community-acquired pneumonia who has suddenly become impossible to ventilate. SAQs which actually involved the management of raised ICP have included:

  • Question 29 from the second paper of 2021 (aneurysm clip fell off)
  • Question 6 from the second paper of 2015 (aneurysm clip fell off again)
  • Question 28 from the second paper of 2011 (sedation not working on ICP, halp)
  • Question 12 from the first  paper of 2004 (generic principles of ICP control)
  • Question 5 from the second paper of 2002 (generic principles of ICP control)

This "tiered" approach SAQ likely refers to the 2019 SIBICC algorithm, and appears to be a test of the candidates' ability to reproduce these guidelines and apply them safely.


  • Tier Zero: basic neuroprotective strategies
    • Elevated head of bed
    • Fever prevention
    • Removal of tight tube ties
    • Removal of C-spine collar
  • Tier One:
    • ​​​​​​​Increase analgesia 
    • Increase sedation
    • Maintain low-normal PaCO2 (35-38 mmHg)
    • Mannitol or hypertonic saline bolus (up to an osmolality of 320 mOsm/kg, or a sodium of 155 mmol/L)
    • CSF drainage by EVD
  • Tier Two:
    • ​​​​​​​Hyperventilate to 32-35 mmHg
    • Use neuromuscular paralysis
    • perform MAP challenge (increase MAP by 10mmHg to asssess autoregulation; if the ICP does not rise, autoregulation is intact) - if autoregulation is intact, use fluids/vasopressors/inotropes to increase CPP to 60-70
  • Tier Three:
    • ​​​​​​​Thiopentone coma
    • Decompressive craniectomy
    • Therapeutic hypothermia (35-36 C)
  • Use of the tiered approach:
    • ​​​​​​​When possible, use the lowest tier
    • Move to the next tier if the ICP remains raised (CPP below 60-70)
    • It is not necessary to use all the modalities within a tier before moving to the next tier
    • Tiers can be skipped if this is considered advantageous