In a patient with an external ventricular drain who becomes suddenly disoriented and intracranial pressure rises from 15 mm Hg to 22 mm Hg, with no visible blockage and no cerebrospinal fluid drainage, what is the highest‑priority intervention?

Inform the Provider Immediately

The highest priority intervention is to inform the provider of the assessment and EVD status. When an EVD suddenly stops draining despite no visible blockages and CSF fluid fluctuation is absent, this represents a potential catheter malfunction or occlusion that requires immediate physician evaluation and likely neurosurgical intervention 1.

Why Provider Notification Takes Priority

Never flush an EVD toward the patient – this is absolutely contraindicated because flushing with a transducer-flush device can generate air emboli within the ventricular system, which can be catastrophic 1. This eliminates the fourth option entirely.

The clinical scenario describes:

• Acute neurological deterioration (new disorientation)
• Rising ICP from 15 to 22 mm Hg (crossing the threshold where intervention is typically needed)
• Non-functioning EVD despite no visible obstruction
• Absent CSF fluctuation (indicating the catheter is not communicating with the ventricular system)

This constellation requires urgent physician assessment because the EVD may need replacement, repositioning, or alternative ICP management strategies 2.

Why Other Options Are Insufficient

Re-leveling the EVD would be appropriate if there were technical issues with transducer positioning or if CSF fluctuation were still present, but when there is no CSF fluctuation at all, the problem is catheter malfunction, not leveling 1. Re-leveling will not restore drainage from a non-functioning catheter.

Administering mannitol (0.25-2 g/kg IV over 30-60 minutes) is indicated for elevated ICP, but should not be the first-line response when the primary problem is EVD malfunction 3. The FDA labeling indicates mannitol should produce evidence of reduced CSF pressure within 15 minutes, but this addresses the symptom (elevated ICP) rather than the underlying cause (non-draining EVD) 3. Additionally, mannitol requires careful evaluation of circulatory and renal reserve and careful attention to fluid/electrolyte balance 3.

The Correct Management Algorithm

1. Immediately notify the provider of the acute change in mental status, ICP elevation, and EVD malfunction 1

2. The provider will assess whether the catheter needs replacement, repositioning, or if alternative interventions are needed 2

3. Verify system integrity by checking drainage system connections and zeroing the pressure transducer to the external auditory meatus, but only after provider notification 1

4. Medical management (such as mannitol) may be initiated by the provider while definitive EVD management is arranged, but this is a temporizing measure 3

Critical Safety Points

• EVD manipulation should only occur after confirming adequate coagulation status, as invasive catheter handling increases intracranial bleeding risk 1
• When a damped ICP waveform is observed with absent CSF fluctuation, this indicates catheter malfunction requiring neurosurgical evaluation 1
• External ventricular drains are high-risk devices, and infection risk increases significantly beyond 5-7 days of drainage 1

The nursing priority is recognition and escalation of this emergency situation, not independent intervention with medications or equipment manipulation.