Cushing's reflex

• Increased ICP → bradycardia, hypertension, wide pulse pressure, irregular breathing
• May indicate imminent herniation

Herniation

• Altered LOC
• Respiratory irregularity, hyperventilation, or apnea
• Uncal - ipsilateral dilated pupil, hemiparesis
• Central - pupils midposition + fixed; posturing

1. Clarify goals of care
2. Call neurosurgery STAT
3. Lower intracranial pressure
• Hyperventilation - intubate/bag-mask and hypervent to PCO₂ of 20-30 (→ cerebral vasoconstriction); effective in minutes
• Mannitol - 1-2 g/kg IV over 10-20 min (hyperosmolar → reduces free water in brain); peak effect ~90 min
• If edema from tumor/abscess/infarct - reduce with dexamethasone 10 mg IV, then 4 mg IV q6h
4. Correct coagulopathy if hemorrhage or needs surgery