Intracranial Pressure

Intracranial Pressure
• Skull has three
essential
components:
1. Brain tissue
2. Blood
3. Cerebrospinal fluid
(CSF)
Primary versus Secondary Injury
• Occurs @ time of • Resulting hypoxia,
injury ischemia,
• Impact of car hypotension, edema
accident, blunt force or increased ICP that
trauma follows primary
• Resulting in
displacement,
bruising or damage to
skull components
Intracranial Pressure
• Hydrostatic force • Factors that
measured in the influence ICP
brain CSF • Arterial pressure
• Venous pressure
compartment
• Intraabdominal and
intrathoracic pressure
• Posture
• Temperature
• Blood gases (CO2
levels)
Regulation and Maintenance
• Monro-Kellie • Normal compensatory
adaptations
doctrine • Changes in CSF volume
• If one component • Changes in intracranial
increases, another blood volume
must decrease to • Changes in tissue brain
maintain ICP volume
• Ability to compensate is
• Normal ICP 5 to 15 limited
mm Hg • If volume increase
• Elevated if >20 mm continues, ICP rises →
decompensation
Hg sustained
Cerebral Blood Flow
• Definition • Autoregulation
• Amount of blood in • Adjusts diameter of
mL passing through blood vessels
100 g of brain tissue • Ensures consistent
in 1 minute CBF
• About 50 mL/min per • Only effective if mean
100 g of brain tissue arterial pressure
(MAP) 70 to 150 mm
Hg
Cerebral Blood Flow
• Cerebral perfusion pressure (CPP)
• CPP = MAP – ICP
• Normal is 60 to 100 mm Hg
• <50 mm Hg is associated with ischemia
and neuronal death
• Effect of cerebral vascular resistance
• CPP = Flow x Resistance
Cerebral Blood Flow
• Stages of increased ICP
• Stage 1: Total compensation
• Stage 2: ↓ Compensation; risk for ↑ICP
,
• Stage 3: Failing compensation; clinical
manifestations of ↑ ICP (Cushing’s
triad)
• Stage 4: Herniation imminent → death
 Increased ICP
• Life-threatening
• Increase in any of
three components
• Brain tissue
• Blood
• CSF
• ↑ Cerebral edema
Cerebral Edema
• ↑ Extravascular fluid in brain
• Variety of causes
• Three types of cerebral edema
1. Vasogenic
2. Cytotoxic
3. Interstitial
Cerebral Edema
• Vasogenic cerebral • Cytotoxic cerebral
edema edema
• Most common type • Disruption of cell
• Occurs mainly in white membrane integrity
matter • Secondary to
• Fluid leaks from destructive lesions or
intravascular to trauma to brain
extravascular space tissue
• Variety of causes • Fluid shift from
• Continuum of extracellular to
symptoms → coma intracellular
Cerebral Edema
• Interstitial cerebral edema
• Usually result of hydrocephalus
• Excess CSP production, obstruction of
flow, or inability to reabsorb
• Treat with ventriculostomy or shunt
 Clinical Manifestations
• Change in level of
consciousness
• Coma or change in
attention span
• Change in vital signs
• Cushing’s triad
• Ocular signs
Clinical Manifestations
• Change in level of consciousness
• Flattening of affect → stupor to coma
• Change in vital signs: LATE SIGNS
• Cushing’s triad (Systolic HTN
w/widened pulse pressure, bradycardia
[slow, full, bounding pulse,, irregular
respirations)
• Change in body temperature
Clinical Manifestations
• Compression of • Other cranial nerves
oculomotor nerve • Diploplia, blurred
• Unilateral pupil vision, EOM changes
dilation
• Sluggish or no
response to light
• Inability to move eye
upward
• Eyelid ptosis
 Clinical Manifestations
• ↓ In motor function
• Hemiparesis/hemiple
gia
• Decerebrate
posturing (extensor)
• Indicates more serious
damage
• Decorticate posturing
(flexor)
 Clinical Manifestations
• Headache • Inadequate cerebral
• Often continuous
perfusion
• Worse in the morning
• Assess for SIADH or
• Vomiting
DI
• Not preceded by
• Cerebral herniation
nausea
• Projectile • Tentorial herniation
• Uncal herniation
• Cingulate herniation
Diagnostic Studies
• CT scan / MRI / PET
• EEG
• Cerebral angiography
• ICP and brain tissue oxygenation
measurement (LICOX catheter)
• Doppler and evoked potential studies
• NO lumbar puncture
Measurement of ICP
• Guides clinical care
• Indications
• Glasgow Coma Scale
of ≤8
• Abnormal CT scans or
MRI
Measurement of ICP
• Ventriculostomy
• Catheter inserted into lateral ventricle
• Coupled with an external transducer
Leveling a Ventriculostomy

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Measurement of ICP
• Fiberoptic catheter • Prevent and monitor
• Sensor transducer for infection
located within • Measure as mean
catheter tip
pressure
• Air pouch/pneumatic
• Waveform should be
technology
recorded
• Air-filled pouch at
• Normal, elevated,
catheter tip
and plateau waves
ICP Monitoring

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 Measurement of ICP
• Evaluate changes with patient
condition
• Inaccurate readings caused by
• CSF leaks
• Obstruction in catheter/ kinks in tubing
• Differences in height of bolt/transducer
• Incorrect height of drainage system
• Bubbles/air in tubing
Measurement of ICP
• Can control ICP by removing CSF
(with ventricular catheter)
• Intermittent or continuous drainage
• Careful monitoring of volume of CSF
drained is essential
• Prevent infection and other
complications
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Measurement of Cerebral
Oxygenation and Perfusion
• LICOX catheter
• Measures brain
oxygenation (PbtO2)
and temperature
• Placed in healthy
white brain matter
• Jugular venous bulb
catheter
• Measures jugular
venous oxygen
saturation (SjvO2)
Interprofessional Care
• Treat underlying cause
• Adequate oxygenation
• PaO2 > 100 mm Hg
• PaCO2 35-45 mm Hg
• Intubation
• Mechanical ventilation
• Surgery
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Interprofessional Care
• Drug Therapy • Corticosteroids
• Mannitol (Osmitrol) [dexamethasone
• Plasma expansion {Decadron}
• Osmotic effect • Vasogenic edema
• Monitor fluid and • Monitor fluid intake,
electrolyte status serum sodium and
• Hypertonic saline glucose levels
• Moves water out of • Concurrent antacids,
cells and into blood H2 receptor blockers,
• Monitor BP and serum proton pump
sodium levels inhibitors
Interprofessional Care
• Drug Therapy
• Antiseizure medications
• Antipyretics
• Sedatives
• Analgesics
• Barbiturates
Interprofessional Care
• Nutritional Therapy
• Hypermetabolic and hypercatabolic
state ↑ need for glucose
• Enteral or parenteral nutrition
• Early feeding (within 3 days of injury)
• Keep patient normovolemic
• IV 0.9% NaCl preferred over D5W or
0.45% NaCl
Nursing Assessment
• Subjective data
• Level of consciousness (LOC)
• Glasgow Coma Scale
• Eye opening
• Best verbal response
• Best motor response
Pupillary Check for
Size and Response

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Nursing Assessment
• Cranial nerves
• Eye movements
• Corneal reflex
• Oculocephalic reflex (doll’s eye reflex)
• Oculovestibular (caloric stimulation)

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Nursing Assessment
• Motor strength
• Squeeze hands
• Pronator drift test
• Raise foot off bed or bend knees
• Motor response
• Spontaneous or to pain
• Vital signs
Abnormal Respiratory Patterns of
Coma
Nursing Planning
• Overall Goals
• Maintain a patent airway
• ICP within normal limits
• Normal fluid and electrolyte balance
• Prevent complications secondary to
immobility and decreased LOC
Acute Care
• Respiratory function
• Maintain patent airway
• Elevate head of bed 30 degrees
• Suctioning needs
• Minimize abdominal distention
• Monitor ABGs
• Maintain ventilatory support
Acute Care
• Pain and anxiety management
• Opioids
• Propofol (Diprivan)
• Dexmedetomidine (Precedex)
• Neuromuscular blocking agents
• Benzodiazepines

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Acute Care
• Fluid and electrolyte balance
• Monitor IV fluids
• Daily electrolytes
• Monitor for DI or SIADH
• Monitor and minimize increases in
ICP

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Acute Care
• Interventions to optimize ICP and
CPP
• HOB elevated appropriately
• Prevent extreme neck flexion
• Turn slowly
• Avoid coughing, straining, Valsalva
• Avoid hip flexion
Acute Care
• Minimize complications of
immobility
• Protection from self-injury
• Judicious use of restraints; sedatives
• Seizure precautions
• Quiet, nonstimulating environment
• Psychologic considerations
 Audience Response Question

A patient with increased ICP is positioned in a lateral

position with the head of the bed elevated 30 degrees.
The nurse evaluates a need for lowering the head of the
bed when the patient experiences
a. ptosis of the eyelid.
b. unexpected vomiting.
c. a decrease in motor functions.
d. decreasing level of consciousness.