Increase Intracranial Pressure

Brain Brain tissue (1,400g) Blood (75mL) CSF (75mL) Normal ICP 10 to 20 mmHg

Monro-Kellie Hypothesis Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others.

Pathophysiology

Increase ICP is a syndrome that affects many patients with acute neurologic conditions. This is because pathologic conditions alter the relationship between intracranial volume and pressure.

Elevated ICP most commonly associated with head injury Secondary Effects Brain tumors Subarachnoid hemorrhage Toxic and viral encephalities

Diagnostic Findings

Cerebral Angiography Computed Tomography (CT) Scanning Magnetic Resonance Imaging (MRI) Positron Emission Tomography (PET) Transcranial Doppler

Cerebral Angiography The first image shows normal brain blood flow The second image shows presence of cerebral aneurysm that can cause decease cerebral blood flow may lead to increase ICP

Computed Tomography Scanning The first image shows a normal view of the brain The second image shows brain with tumor and edema that may lead to increase ICP

Magnetic Resonance Imaging The first image shows normal MRI result The second image shows with brain tumor that causes increase ICP

Positron Emission Tomography The first image shows normal PET result The second image shows with brain tumor that may lead to increase ICP

Transcranial Doppler The top shows a TCD of a normal artery Bottom shows a severely stenosed internal carotid artery causes decrease cerebral blood flow may lead to increase ICP

ICP Precautions Elevate head of bed 30 degrees. Seizure prophylaxis: Phenytoin will reduce seizures in the first week after injury but does not change the overall outcome. Steroids are ineffective in controlling ICP in the trauma setting.

Manipulation of ICP Blood Decrease cerebral metabolic demand sedation, analgesia, barbiturates avoid hyperthermia avoid seizures Hyperventilation decreases blood flow to brain only acutely for impending herniation Mannitol

Manipulation of ICP Brain Mannitol Hypertonic saline dehydrate the brain, not the patient! monitor osmolality Hypertonic saline Decompressive craniectomy

ICP Monitoring ICU patients who have sustained head trauma, brain hemorrhage, brain surgery, or conditions in which the brain may swell might require intracranial pressure monitoring. The purpose of ICP monitoring is to continuously measure the pressure surrounding the brain.

Why Monitor? Detect “events” Manage intracranial pressure Manage cerebral perfusion pressure

How? Ventriculostomy Intraparenchymal fiberoptic catheter Subarachnoid monitor Useful adjuncts: Arterial line Central venous line Foley catheter

Manipulation of ICP CSF External drainage therapeutic as well as diagnostic technical issues infectious issues

What to do with the information... Goal: adequate oxygen delivery to maintain the metabolic needs of the brain. Intracranial pressure <20 Cerebral perfusion pressure >50-70 mm Hg CPP=MAP-ICP

Indications for ICP monitoring Glasgow coma scale <8 Clinical or radiographic evidence of increased ICP Post-surgical removal of intracranial hematoma Less severe brain injury in the setting which requires deep sedation or anesthesia

Management of Raised ICP Measure ICP Maintain CPP>70 mm Hg Management of Raised ICP Raised ICP>25mm Hg First Line Rx Ventricular Drain Raised ICP>25mm Hg CT Normal Vent/Oxygenation Mannitol Sedation

Management of Raised ICP Maintain CPP>70 mm Hg Management of Raised ICP Raised ICP>25mm Hg Furosemide Chemical Paralysis CSF Removal Vasopressor Second Line Rx Raised ICP>25mm Hg Barbiturates Hyperventilation Monitor SjO2

The Patient with Increased Intracranial Pressure Nursing Process The Patient with Increased Intracranial Pressure

Assessment

History Present Illness Obtain Subjective Data Neurologic examination Mental Status LOC Cranial Nerve Function Cerebral Function (balance and coordination) Reflexes Motor and Sensory Function Abnormal Respiratory Pattern

Nursing Diagnosis

Ineffective airway clearance related to diminished protective reflexes Ineffective breathing patterns related to neurologic dysfunction Ineffective cerebral tissue perfusion related to the effects of increased ICP Deficient fluid volume related to fluid restriction Risk for infection related to ICP monitoring system

Planning and Goals

Maintenance of patent airway Normalization of respiration Adequate cerebral tissue perfusion through reduction in ICP Restoration of fluid balance Absence of infection Absence of complication

Nursing Intervention

Maintaining patent airway and adequate ventilation Monitor vital signs and neurochecks Maintain fluid balance Position client with head of the bed elevated 30 to 45 degrees and neck in neutral position Maintain a quiet environment Avoid use of restraints Prevent straining at stool Prevent excessive cough and vomiting Prevent complication of immobility Preventing infection Administer medication as ordered

Evaluation

Maintained patent airway Attains optimal breathing pattern Attains desired fluid balance Infection prevented Complications prevented