Increased Intracranial Pressure and Brain Herniation Practice Questions

25 multiple-choice questions on Increased intracranial pressure and brain herniation for paramedic and EMT students, from Chapter 35 (Head and Spine Trauma). Read each question, pick your answer, then tap Show answer to check it and read the explanation.

25 practice questions

1. A head-injured patient with severe pain from a femur fracture needs analgesia. The best approach is to:

   1. A. Withhold all pain medication completely
   2. B. Give a large opioid dose to sedate fully
   3. C. Give it only after the CT scan is complete
   4. D. Give small, titrated doses and recheck GCS
   Show answer

   Answer: D. Give small, titrated doses and recheck GCS

   Pain control is appropriate in head-injured patients, but opioids can depress breathing (raising CO2 and ICP), lower blood pressure, and cloud the neurologic exam. Small, titrated doses with monitoring of GCS, pupils, ventilation, and blood pressure balance these risks. Withholding all analgesia is unnecessary, and large sedating doses are unsafe.

2. A 42-year-old assaulted with a bat now responds only to pain. His BP is 196/104 mm Hg, pulse 46 beats/min, and respirations are irregular with pauses. These findings most strongly suggest:

   1. A. Neurogenic shock from a cervical injury
   2. B. Hypertensive crisis unrelated to trauma
   3. C. Brainstem compression from rising ICP
   4. D. Hemorrhagic shock from internal bleeding
   Show answer

   Answer: C. Brainstem compression from rising ICP

   Rising blood pressure, slowing pulse, and erratic breathing in a head-injured patient are Cushing triad and signal impending herniation. Neurogenic shock produces hypotension, not hypertension, with bradycardia.

3. The blood pressure pattern that typically accompanies rising ICP is:

   1. A. Rising systolic pressure with a widening pulse pressure
   2. B. Falling systolic pressure with a narrowing pulse pressure
   3. C. Steady systolic pressure with a falling diastolic pressure
   4. D. Falling systolic pressure with a rising diastolic pressure
   Show answer

   Answer: A. Rising systolic pressure with a widening pulse pressure

   The systolic pressure climbs as the body tries to push blood into the skull, widening the gap between systolic and diastolic pressures. A narrowing pulse pressure is typical of hypovolemic shock instead.

4. The earliest and most sensitive sign of increasing intracranial pressure is usually:

   1. A. A fixed and dilated pupil
   2. B. A declining level of consciousness
   3. C. Extensor (decerebrate) posturing of the limbs
   4. D. Bradycardia with hypertension
   Show answer

   Answer: B. A declining level of consciousness

   Changes in mental status, such as confusion, restlessness, or drowsiness, appear well before pupil changes, posturing, or Cushing triad. Waiting for a blown pupil means waiting until herniation is under way.

5. A head-injured patient has bilaterally fixed and dilated pupils. Before assuming brainstem herniation, you should consider whether he:

   1. A. Has taken an opioid recently
   2. B. Has a cervical spine injury
   3. C. Received ondansetron for nausea
   4. D. Is hypoxic or got eye drops
   Show answer

   Answer: D. Is hypoxic or got eye drops

   Bilaterally fixed, dilated pupils after head injury usually signal severe brain injury, but profound hypoxia, hypotension, and drugs (such as mydriatic eye drops or some poisons) can also cause them, and correcting hypoxia may restore reactivity. Opioids constrict rather than dilate the pupils, a cervical cord injury may produce a small pupil (Horner syndrome) rather than bilateral dilation, and ondansetron does not affect pupil size.

6. A patient with a head injury has a fixed, dilated right pupil and weakness of the left arm and leg. The expanding lesion is most likely located on the:

   1. A. Left side of the brain
   2. B. Left side of the spinal cord
   3. C. Right side of the brain
   4. D. Right side of the spinal cord
   Show answer

   Answer: C. Right side of the brain

   The pupil usually dilates on the same side as the mass, and because motor tracts cross, the weakness appears on the opposite side. The pupil is the more reliable lateralizing sign.

7. A head-injured patient does not move at all in response to a firm painful stimulus. This motor response:

   1. A. Scores 1, the lowest motor GCS score
   2. B. Scores 3, the same as abnormal flexion
   3. C. Means the patient is likely just asleep
   4. D. Cannot be scored on the Glasgow Coma Scale
   Show answer

   Answer: A. Scores 1, the lowest motor GCS score

   No motor response to pain is scored M1, the worst motor score, and suggests a very severe brain injury (or spinal cord injury, intoxication, or paralysis, which should be considered). Abnormal flexion scores 3. A sleeping patient would respond to pain, and flaccidity is scored, not omitted.

8. A 30-year-old with a severe head injury now responds to pain by extending his arms and legs and internally rotating his arms. Compared with flexion posturing, this finding indicates:

   1. A. Improvement in his neurologic status
   2. B. Deeper injury involving the brainstem
   3. C. Spinal cord injury rather than TBI
   4. D. A seizure that will stop on its own
   Show answer

   Answer: B. Deeper injury involving the brainstem

   Extensor (decerebrate) posturing reflects damage at the level of the brainstem and carries a worse prognosis than flexion. A change from flexion to extension is a sign of worsening, not improvement.

9. A head-injured patient breathes deeply and rapidly at 40 breaths/min in a regular pattern, despite adequate oxygenation. This pattern is called:

   1. A. Cheyne-Stokes respirations
   2. B. Ataxic (Biot) respirations
   3. C. Agonal gasping respirations from hypoxia
   4. D. Central neurogenic hyperventilation
   Show answer

   Answer: D. Central neurogenic hyperventilation

   Sustained rapid, deep breathing with an injured brain suggests a lesion in the lower midbrain or upper pons. Cheyne-Stokes breathing waxes and wanes with periods of apnea, and ataxic breathing is completely irregular.

10. An alert patient with a moderate TBI is nauseated and retching repeatedly during transport. Treating this with an antiemetic per protocol is helpful mainly because retching and vomiting:

    1. A. Lower ICP by emptying the stomach
    2. B. Raise ICP and risk aspiration
    3. C. Confirm a skull base fracture
    4. D. Cause a metabolic acidosis quickly
    Show answer

    Answer: B. Raise ICP and risk aspiration

    Retching and vomiting cause straining that raises intrathoracic and intracranial pressure, and vomiting threatens the airway, especially as consciousness changes. An antiemetic such as ondansetron, positioning to protect the airway, and suction ready are appropriate. Emptying the stomach does not lower ICP, repeated vomiting tends to cause alkalosis rather than acidosis through loss of stomach acid, and although vomiting warrants close neurologic reassessment, it does not confirm a skull base fracture.

11. Which head-injured patient meets current criteria for brief controlled hyperventilation?

    1. A. GCS of 6 with extensor posturing
    2. B. GCS of 13 with repeated vomiting
    3. C. GCS of 10 with a severe headache
    4. D. GCS of 15 with a scalp laceration
    Show answer

    Answer: A. GCS of 6 with extensor posturing

    A GCS of 8 or less with extensor posturing is a sign of active or impending herniation, the only situation in which the Brain Trauma Foundation supports brief controlled hyperventilation. The 2023 prehospital guideline lists herniation signs as a GCS below 9 with posturing or lateralizing findings, one or two fixed and dilated pupils, Cushing triad, or progressive neurologic deterioration; it no longer uses a fixed 2-point GCS drop as the threshold. Repeated vomiting with a GCS of 13, a severe headache with a GCS of 10, and a scalp laceration with a GCS of 15 are all concerning but are not herniation signs, so these patients are ventilated to normal ETCO2 (35 to 45 mm Hg) only if they need ventilation at all.

12. When ventilating an intubated adult TBI patient, besides the rate, you should avoid excessive tidal volumes mainly because large breaths:

    1. A. Improve brain blood flow at all times
    2. B. Raise the blood pressure very sharply
    3. C. Are needed to prevent the brain swelling
    4. D. Lower CO2 and can reduce venous return
    Show answer

    Answer: D. Lower CO2 and can reduce venous return

    Oversized breaths blow off CO2 (constricting cerebral vessels and reducing brain blood flow) and raise intrathoracic pressure, which can lower venous return and blood pressure. Tidal volumes of about 6 to 8 mL/kg guided by chest rise and capnography are appropriate. Large breaths do not reliably improve brain perfusion or prevent swelling.

13. For an adult with signs of herniation, the commonly taught starting rate for brief hyperventilation, adjusted to an ETCO2 of 30 to 35 mm Hg, is about:

    1. A. 10 breaths/min
    2. B. 30 breaths/min
    3. C. 20 breaths/min
    4. D. 40 breaths/min
    Show answer

    Answer: C. 20 breaths/min

    Adults with signs of herniation are traditionally ventilated at about 20 breaths/min (children 25, infants 30), and the current BTF guideline frames the goal as an ETCO2 of 30 to 35 mm Hg, so capnography, not the rate alone, sets the final rate. Ten breaths/min is the normal adult rate without herniation and will not lower CO2. Thirty breaths/min is the infant herniation rate and would overshoot an adult into dangerous hypocapnia. Forty breaths/min causes severe vasoconstriction and air trapping.

14. A 7-month-old with a severe head injury develops a fixed, dilated pupil and extensor posturing. If hyperventilation is ordered, the commonly taught starting rate, adjusted to an ETCO2 of 30 to 35 mm Hg, is about:

    1. A. 20 breaths/min
    2. B. 40 breaths/min
    3. C. 25 breaths/min
    4. D. 30 breaths/min
    Show answer

    Answer: D. 30 breaths/min

    The traditional herniation rates are about 20 breaths/min for adults, 25 for children, and 30 for infants younger than 1 year, with capnography guiding the rate toward an ETCO2 of 30 to 35 mm Hg. Twenty breaths/min is the adult herniation rate (and close to the normal infant rate of about 25), too slow to lower an infant's CO2. Twenty-five breaths/min is the child herniation rate, not the infant rate. Forty breaths/min risks profound hypocapnia and cerebral ischemia.

15. Routine prophylactic hyperventilation of every patient with a severe TBI is not recommended because it:

    1. A. Constricts cerebral vessels and causes ischemia
    2. B. Raises ICP by dilating the cerebral arteries further
    3. C. Causes respiratory acidosis in most patients
    4. D. Increases cerebral blood flow beyond normal
    Show answer

    Answer: A. Constricts cerebral vessels and causes ischemia

    Lowering CO2 constricts cerebral arteries and reduces ICP, but at the cost of blood flow to already injured tissue. Respiratory acidosis is the result of hypoventilation, not hyperventilation.

16. You are hyperventilating a patient who showed a blown pupil and extensor posturing. Five minutes later, both pupils are equal and reactive and the posturing has stopped. You should:

    1. A. Increase the rate to keep the ETCO2 near 25
    2. B. Continue hyperventilating until hospital arrival
    3. C. Return to normal ventilation with ETCO2 35 to 45
    4. D. Stop ventilating and allow spontaneous breathing
    Show answer

    Answer: C. Return to normal ventilation with ETCO2 35 to 45

    Hyperventilation is a temporary bridge used only while herniation signs are present; once they resolve, return to normoventilation to protect cerebral blood flow. Continuing it prolongs vasoconstriction without benefit.

17. In a head-injured patient with an adequate blood pressure and spinal motion restriction in place, elevating the head of the stretcher about 30 degrees helps by:

    1. A. Increasing arterial flow into the brain
    2. B. Improving venous drainage from the brain
    3. C. Raising cerebral perfusion pressure directly
    4. D. Lowering the blood pressure to reduce bleeding
    Show answer

    Answer: B. Improving venous drainage from the brain

    Raising the head, by tilting the whole stretcher if the spine is restricted, eases venous outflow and lowers ICP. It should not be done when the patient is hypotensive, because it can lower cerebral perfusion.

18. A head-injured patient has an endotracheal tube secured with ties pulled very tightly around the neck and a cervical collar that is too small. The concern is that these can:

    1. A. Dislodge the tube into the right mainstem
    2. B. Obstruct jugular venous return and raise ICP
    3. C. Cause hypercapnia by restricting chest rise
    4. D. Lower blood pressure by compressing carotids
    Show answer

    Answer: B. Obstruct jugular venous return and raise ICP

    Compression of the jugular veins slows outflow of blood from the skull and raises ICP. Tube ties and collars should be snug but not constricting.

19. A head-injured patient's BP rises to 210/110 mm Hg as his heart rate falls. The appropriate response to the hypertension is to:

    1. A. Give a nitrate to bring the pressure down
    2. B. Give a beta-blocker to slow the heart rate
    3. C. Lower it by 25% within the first hour
    4. D. Treat it as compensation and not lower it
    Show answer

    Answer: D. Treat it as compensation and not lower it

    In Cushing reflex, the hypertension is the body's attempt to maintain cerebral perfusion against a high ICP; lowering it can cause brain ischemia. Treat the cause by optimizing ventilation and transporting rapidly.

20. In a hypotensive patient with a severe TBI and signs of herniation, hypertonic saline is often preferred over mannitol mainly because mannitol:

    1. A. Has no effect at all on intracranial pressure
    2. B. Must be mixed with blood before it is given
    3. C. Causes a diuresis that can worsen hypotension
    4. D. Raises intracranial pressure in most patients
    Show answer

    Answer: C. Causes a diuresis that can worsen hypotension

    Both agents draw water out of the brain, but mannitol is an osmotic diuretic that can lower blood volume and blood pressure, while hypertonic saline expands intravascular volume, which is helpful when the patient is hypotensive. Mannitol does lower ICP, is not mixed with blood, and does not raise ICP.

21. A patient with a moderate TBI begins a generalized seizure en route. The seizure is harmful mainly because it:

    1. A. Increases cerebral oxygen demand and ICP
    2. B. Lowers blood pressure and slows the pulse
    3. C. Raises oxygen demand but lowers the ICP
    4. D. Causes hypocapnia that constricts vessels
    Show answer

    Answer: A. Increases cerebral oxygen demand and ICP

    Seizure activity sharply raises brain metabolism and oxygen use, often while breathing is impaired, worsening secondary injury. It should be stopped promptly with a benzodiazepine per protocol. The surge in metabolism and blood flow raises ICP rather than lowering it, seizures tend to raise CO2 rather than lower it, and they usually raise rather than lower the blood pressure and pulse.

22. Avoiding fever in a patient with a severe TBI is important because hyperthermia:

    1. A. Lowers cerebral blood volume
    2. B. Raises cerebral metabolic demand
    3. C. Prevents cerebral edema forming
    4. D. Constricts the cerebral arteries
    Show answer

    Answer: B. Raises cerebral metabolic demand

    Each degree of temperature increase raises the brain's oxygen consumption, worsening any mismatch between supply and demand. Fever does not protect against edema; it tends to worsen secondary injury.

23. A patient with an expanding hematoma has been stable for 20 minutes, then suddenly deteriorates over a few minutes. The best explanation is that:

    1. A. The hematoma has stopped expanding further
    2. B. Cerebral autoregulation has been restored
    3. C. Compensatory volume reserves are exhausted
    4. D. CSF production has increased to compensate
    Show answer

    Answer: C. Compensatory volume reserves are exhausted

    Once CSF and venous blood have been displaced, the intracranial pressure-volume curve becomes steep, and small additions of volume cause large ICP rises. This is why patients can appear stable and then crash quickly.

24. Herniation of the cerebellar tonsils through the foramen magnum is rapidly fatal because it:

    1. A. Blocks blood flow to the occipital lobes
    2. B. Tears the middle meningeal artery
    3. C. Compresses the optic nerves at the chiasm
    4. D. Compresses the medulla and stops breathing
    Show answer

    Answer: D. Compresses the medulla and stops breathing

    The medulla contains the respiratory and cardiovascular centers, so tonsillar herniation causes apnea and cardiovascular collapse. Occipital ischemia can occur with other herniation types but is not the immediate cause of death.

25. A 25-year-old with a head injury has projectile vomiting, a worsening headache, and increasing drowsiness. These findings are best explained by:

    1. A. Rising intracranial pressure
    2. B. Postconcussive syndrome
    3. C. A cervical spinal cord injury
    4. D. Low cerebral blood volume
    Show answer

    Answer: A. Rising intracranial pressure

    Headache, vomiting, and declining consciousness form the early picture of increasing ICP. Prepare to suction and protect the airway, and reassess pupils and GCS frequently. Postconcussive syndrome develops over days to weeks and does not cause increasing drowsiness, a cervical cord injury causes weakness and sensory loss rather than this picture, and a low cerebral blood volume would lower rather than raise ICP.