Fig. 1

Summary of the available ICP-directed therapies. Before starting an HICP-directed therapy, I consider removing confounders (summarised in ESM as malfunctioning of ICP monitoring devices, pneumothorax, hypoxia, hypercapnia, pain, hypo/hypertension, hyperpyrexia, seizures, hypo-osmolality). These factors need to be corrected early with specific therapeutical manoeuvres. In all TBI patients, I consider always obtaining an early neurosurgical opinion on surgery for intracranial mass lesions and if the patient presents a clinical or imaging neuroworsening. I will escalate TIL (therapy intensity level) accordingly to the ICP response. The progression I use is summarised in the TILs described below. The therapies with a * are short lasting. TIL 1—Basic. If ICP is > 20–22 mmHg, consider head-up positioning (15–30°), sedation and analgesia: propofol 4–6 mg/kg/h, opioids: fentanyl 1–4 mcg/kg/h), mild hypocapnia* (PaCO₂ = 35 mmHg), normothermia and antiepileptics (if the patents has seizures or non-convulsive status). Maintain CPP 50–70 mmHg according to autoregulatory status. The risks and level of evidence for these therapies are low but this bundle is effective in many patients for controlling ICP. TIL 2—Mild. If ICP is > 20–25 mmHg with TIL-1 therapies, I consider the following: increasing sedation (side effect: hypotension and need of vasoactive drugs), CSF drainage* inserting external ventricular drainage (side effect: infections, hematoma), osmotherapy* (mannitol and/or hypertonic saline. Maintain a euvolemic status) and mild hypocapnia*. Maintaining CPP 50–70 mmHg according to autoregulatory status. If pressure autoregulation is preserved, higher CPP (around 70 mmHg) is tolerated and might reduce ICP maintaining cerebral blood flow. If pressure autoregulation is not preserved, higher CPP increases cerebral blood volumes and, consequentially, ICP TIL 3—Moderate. If ICP remains > 20–25 mmHg with TIL-2 therapies, I use higher doses of osmotic* (limits: natremia < 155 mEq, Osm 320), profound hypocapnia* with a brain oxygen monitor. CPP 50–70 mmHg according to autoregulatory status. Consider repeating a CT scan. TIL 4—Extreme. If ICP persists > 25 mmHg, refractory to TIL-3 therapies, consider before using extreme therapies the prognosis of the patient, the best outcome that might be obtained and the patient’s wills and inform the patient’s family. Use barbiturates for “buying time” while discussing the utility of decompressive craniectomy. Evaluate DC soon when TIL 3 therapies have failed. I am using moderate hypothermia only in selected cases. See text for details. A continuous check of the efficacy of the therapies needs to be implemented and, if ICP is controlled, consider moving backwards in the flowchart, deescalating ICP lowering as soon as possible