A patient with an intracranial hemorrhage can look surprisingly stable…until they suddenly don’t. Recognizing the subtle signs of rising intracranial pressure before herniation occurs is one of the most time-critical skills in emergency medicine. In this episode, Drs. James Nardini, Mike Prats, and Kim Bambach discuss a practical, evidence-based approach to critical brain resuscitation, from recognizing early deterioration to implementing tiered ICP management, choosing hyperosmolar therapy, optimizing sedation, and avoiding common pitfalls. Based on the Emergency Neurological Life Support (ENLS) framework, this episode provides a systematic approach you can apply on your next shift.

Guest: James Nardini, MD, MS; Host: Mike Prats, MD and Kim Bambach, MD; Editor: Kim Bambach, MD

Waiting for the full triad means the patient is already critically decompensating.

Tier 0: Optimize physiology

Tier 1: Temporize while arranging for definitive care

Benefits:

Watch for:

Maintain adequate blood pressure while sedating.

A common pitfall is waiting too long to initiate hyperosmolar therapy. If you’re seriously asking whether the patient needs hypertonic therapy, that may be the moment to act rather than waiting for unmistakable herniation.

The goal is to:

Bedside ultrasound may provide additional information: