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David Menon discusses the complex and fraught world of managing traumatic brain injury (TBI) in the ICU. In particular, David discusses the management of intracranial pressure and cerebral perfusion pressure in these patients. Although the Brain Trauma Foundation provides guidelines for the management of severe TBI, including targets for ICP and CCP, there is no Level 1 recommendation for the use of any intervention to modulate ICP/CCP. General principles remain simple in theory, if not in practice. David describes good basic intensive care, which he describes as doing lots of little things well. The main focuses should be maintaining blood pressure high enough to get oxygen to brain, optimising oxygenation and modulating carbon dioxide. This is in combination with other modalities such as hypertonic saline, cooling people, and using metabolic suppression. The trouble lies in the fact that there is no evidence base for second line therapy. In fact, some of these therapies have been shown to cause harm. When c