Which of the following is among the earliest signs of increased intracranial pressure?

• A. Cushing's triad
• B. Unexpected vomiting
• C. Decreasing level of consciousness
• D. Dilated pupil with sluggish response to light

Answer: (B)

The key idea is that early increases in intracranial pressure often manifest with vomiting before other neurological changes appear. The rising pressure can stimulate the brain’s vomiting center in the medulla, producing sudden, unexpected vomiting even without a GI trigger. This makes vomiting one of the first noticeable warning signs of ICP and a cue to assess for other ICP changes promptly.

As ICP continues to rise, you’d expect a decreasing level of consciousness and, later, signs of brainstem involvement such as pupil changes (dilated pupil with sluggish response) and the Cushing reflex (hypertension with widening pulse pressure and bradycardia). These latter findings indicate more advanced pressure and potential herniation, not the earliest changes.