5d • EMT Talk
Why not high fowlers in an ICP patient?
1️⃣ It lowers cerebral perfusion pressure (CPP).
CPP = MAP – ICP
When you sit a patient straight up (60–90°):
- Blood drains out of the brain too quickly
- MAP drops
- This causes CPP to fall, meaning less oxygen and blood reach the brain
Patients with increased ICP are already at risk of brain ischemia → high Fowler’s makes this worse.
2️⃣ It can decrease venous return too much.
High Fowler’s:
- Reduces central venous pressure
- Reduces preload
- Can cause a drop in cardiac output
- Which again → lowers CPP
The brain needs stable blood flow, not sudden drops.
3️⃣ The recommended position is instead 30° (semi-Fowler’s).
This is the sweet spot:
- Promotes venous drainage from the brain
- Reduces ICP
- Does NOT significantly lower MAP or CPP
This is why nearly all trauma/neuro guidelines recommend:
Head of bed elevated 30°, head midline, spine neutral.
⚠️ High Fowler’s may be harmful if the patient is hypotensive.
In trauma, TBI, or shock:
- Sitting upright worsens hypotension
- Hypotension + ICP = catastrophic drop in CPP
- CPP < 60 mmHg → brain ischemia and secondary injury
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Why not high fowlers in an ICP patient?
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