Breathing Support in Head Injury: Why Positive-Pressure Ventilation Can Be Dangerous

Do not provide positive-pressure ventilation (bag-valve-mask, intubation) to a patient with suspected intracranial hemorrhage unless absolutely necessary for oxygenation or ventilation failure.

Physiological Rationale

Positive intrathoracic pressure reduces venous return → increases intracranial pressure (ICP) → worsens cerebral perfusion and raises herniation risk.

Preferred Airway Management

• Maintain airway with jaw thrust, oral/nasal airway.
• High-flow oxygen via non-rebreather mask.
• If GCS ≤8 or respiratory failure: rapid sequence intubation (RSI) with ICP-sparing agents (lidocaine, fentanyl, etomidate/ketamine, rocuronium/succinylcholine).
• Brief hyperventilation (PaCO₂ 30–35 mmHg) only for signs of impending herniation.
• Elevate head 30° if cervical spine clearance allows.

Urgent neurosurgical consultation is mandatory.