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Increased Intracranial
Pressure and Monitoring
This course has been awarded two (2) contact hours.
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Increased Intracranial Pressure and Monitoring
Disclaimer
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Conflict of Interest
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Acknowledgements
RN.com acknowledges the valuable contributions of...
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Purpose
The purpose of Increased Intracranial Pressure and Monitoring is to present information
regarding intracranial hypertension and its effects on patient outcomes.
This course will review intracranial monitoring, monitoring devices, and treatments for
intracranial hypertension. The importance of documentation related to monitoring and
treating intracranial hypertension as well as relevant patient and family education will be
covered.
Learning Objectives
Upon successful completion of this course, you will be able to:
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Introduction
Intracranial pressure refers to the pressure within the intracranial vault (skull).
Early recognition of elevated ICP, use of invasive monitoring, and the initiation of
therapies designed to reduce ICP and address the underlying cause, are important to
improving morbidity and mortality outcomes.
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Anatomy
Ventricular system
Four ventricles comprise the ventricular system within the brain, the largest of which
being the two lateral ventricles. These lateral ventricles are situated deep within the
subcortical tissue one on each side of the midline.
Each lateral ventricle communicates with the third ventricle through the foramen of
Monro. The third ventricle communicates with the fourth ventricle, located in the
medulla, through the aqueduct of Sylvius. The floor of the fourth ventricle is continuous
with the spinal canal. Any blockage within this system will result in some degree of
hydrocephalus and increased intracranial pressure.
CSF functions:
Providing buoyancy and support to the brain and spinal cord
Maintaining a constant extracellular fluid composition for central nervous system
metabolic activity
Providing a medium for unnecessary substances and metabolites removal (Bone
& Lindsay, 1997).
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However, the contents within the skull, brain, blood, and CSF are incompressible.
Hence, if one of the components increases in volume or mass, an overall increase in
pressure within the skull occurs unless another component decreases by the same
volume or mass –Monroe-Kellie Doctrine (Hazinski, 1999).
Brain: 80%
Blood: 7-10%
CSF: 7-10%
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Test Yourself 1
Elevated ICP levels result when a decrease in the volume of one or more components
is offset by a volume reduction/displacement in some other component.
a. True
b. False
Elevated ICP levels result when an increase in the volume in the volume of one or more
components cannot be offset by a volume reduction/displacement in some other
component.
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Arterial oxygen tension: CBF increases when PaO2 is less than 50-55 mm
Hg
Arterial carbon dioxide: CBF increases when PaCO2 increases
Metabolic alterations: CBF increase when potassium, calcium, hydrogen
ions, cytokines, adenosine, or nitric oxide
increases
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Cerebral Compliance
Cerebral compliance is the ability of the intracranial contents to tolerate an increase in
volume without increasing ICP and compromising the brain and cerebral blood flow.
The brain is able to compensate for short term increases in ICP; however, this
compensation is limited and if the cause of the increased ICP is not managed,
progressively smaller changes in volume will significantly increase the ICP.
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ICP is the pressure exerted by the intracranial contents and can be increased by
anything that acutely increases venous pressure, for example: suctioning, coughing,
valsalva maneuvers, and lying down from a sitting position.
The patient’s positioning has an effect on ICP. Patients should be positioned in bed with
their head and neck in midline position and the head of the bed up 30-45 degrees so as
not to impede venous return.
Special Circumstances
Open fontanels, sutures, cranial fractures or a surgically placed bone flap allow the
brain to increase in size without increasing the ICP significantly. These openings in the
skull act as a “pop-off valve” lowering the pressure that might otherwise cause
intracranial hypertension.
Increasing head circumference in the presence of a bone flap or open cranial fractures
may indicate increased ICP with or without a monitoring and drainage device in place
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Test Yourself 2
ICP levels of greater than 20 mm HG for longer than 5 minutes is called
_______________.
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Nursing Alert: Tracheal suctioning has also been linked to increased intracranial
pressure, and thus should only be performed when absolutely clinically necessary and
with close monitoring of the patient before, during, and after the procedure (Moore &
Woodrow, 2009). Interventions that reduce the cough reflex, such as lidocaine lavage
prior to suctioning, should be considered.
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While newer tools are being developed and implemented, this course will only discuss
the Glasgow Coma Scale.
The Glasgow Coma Scale is only a portion of the neurological assessment. This scale
measure the cognitive brain function.
The score is based on the patient’s best response to stimulation and does not designate
muscle strength or symmetry. The scale assigns a numeric value to a patient’s
neurologic response to specific variables.
There are two scales, one for patients under 2 years of age and the other for patients 2
years and older.
The Glasgow Coma Scale can be utilized with acute and chronic patients. It is important
to obtain a baseline score in order that changes can be readily identified and treated.
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A score of 8 or lower correlates with severe brain injury and is the threshold for
intubation and ventilation
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should be reported to the medical provider. For example: a patient with a score of 10
on your last exam now has a score of 8; indicates that the patient’s condition is
deteriorating. Conversely, if the score gets higher, the patient is improving.
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Cushing’s Triad
Cushing's triad refers to a classic presentation which is caused by intracranial
hypertension.
Patients who are not monitored with an ICP monitoring device should be assessed for
Cushing’s Triad symptoms serially. Cushing’s triad may cause focal neurologic deficits
that develop from mass lesions or herniation.
Hypertension
Respiratory
depression/ Bradycardia
disordered breathing
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Test Yourself 3
What are the three signs of Cushing’s Triad that indicate that the pressure in the brain is
increasing?
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The Guidelines for the Management of Severe Head Injury recommends ICP monitoring
in comatose head injury patients if the Glasgow Coma Score (GCS) is 3-8 and an
abnormal CT scan.
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(Chin, 2014)
There are unique risks and benefits to each of the five monitoring devices.
1. Subarachnoid Screw
The subarachnoid screw, also known as a bolt, is placed into the skull, via a burr hole,
abutting the dura.
The positives of this method are that infection and hemorrhage risks are low.
The negative aspects include the possibility of ICP overestimation, misplacement of the
screw, and occlusion by debris.
2. Subdural/Epidural Catheter
The subdural/epidural catheter is placed into the epidural space which is less invasive
but also less accurate. It cannot be used to drain CSF; however, it can be used to
evacuate blood from the epidural space. Because this catheter does not enter the brain,
there is a lower risk of infection (Zhong, Dujovny, Park, Perez, Perlin, & Diaz, 2003).
4. Ventriculostomy
The ventriculostomy, interventricular catheter or drain is a soft tube placed through a
burr hole into the lateral ventricle of the brain. This catheter has the ability to drain CSF
and intermittently measure the ICP when connected to a standard transducer set which
is never pressurized.
In most settings ICP monitoring is only allowable when the drain is off; some systems
allow both to be open at the same time. However, if the drainage catheter becomes
clogged, ICP cannot be measured.
(Zhong et al., 2003).
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Test Yourself 4
The device that allows continuous drainage and monitoring of ICP is:
Rationale: The ventriculostomy placement of a dual use catheter is a soft tube with two
lumen placed through a burr hole into the lateral ventricle of the brain. One lumen
allows drainage for the CSF the other lumen allow for continuous ICP monitoring via a
fiberoptic tip.
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ICP Waveforms
Normal Waveform
A normal ICP waveform generally has 3 distinct components, P1, P2, and P3. If the
waveform is dampened, the patency of the catheter may be compromised. (Kocan, M.
J., 2002).
Normal Waveform
P1 P2 P3
Percussion wave Tidal or Rebound wave Dichroitic wave
First peak, sharp, Second peak, variable Third peak, smallest
consistent amplitude, in shape and amplitude Reflects aortic valve
largest peak May become largest closure
Originates from the wave in the presence of Pressure decreases
choroid plexus decreased compliance to diastolic baseline
pulsations in the (increased
ventricles swelling/edema)
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Abnormal Waveforms
A Waves
ICP Waveform Analysis – Abnormal
These waveforms are always pathological. This represents impaired cerebral blood
flow and occurs with decreases in blood pressure associated with hypovolemia.
Clinical signs: changes in respiratory patterns, pupil dilation, abnormal pupillary
response, sweating, flushing, headache, vomiting, and bradycardia.
B Waves
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C Waves
C- waves are clinically insignificant small waves that occur every 4-8 minutes and
result from fluctuations in systemic pulse and respirations
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Troubleshooting Waveforms
Examine the drainage tubing distal to the patient for the presence of air bubbles, clots,
or tissue. If any are present, flush the tubing away from the patient to remove the debris.
Check for kinks in the tubing and to ascertain if the clamps and stopcocks are open.
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The nurse monitors the patient and assists the neurosurgeon as appropriate.
IMPORTANT: The ventriculostomy catheter should be filled with normal saline that has
no bacteriostatic preservative.
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Drainage
The nurse should monitor the CSF drainage at least hourly for amount, color, and clarity
of drainage. Draining the CSF can be performed continuously or intermittently.
(NIH, 2012)
The stopcock on the transducer set may be open to the drainage systems without
altering the accuracy of the newer systems.
Be sure to read the directions on the system your facility uses and be cognizant of any
changes with the system.
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Test Yourself 5
Managing ICP includes all of the following except:
Rationale: Maintain PCO2 levels about 30 mmHg; lower PCO2 levels cause
vasoconstriction, which may cause cerebral ischemia
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Documentation
ICP and CPP
CSF description
Waveforms
Treatment and outcomes
Assessment
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Family Considerations
Family and significant others are encouraged to visit as family interaction is important to
positive patient outcomes.
Family members often feel the need to stimulate the patient, to get a response that had
not been elicited since the injury; therefore, it is essential that family members be
educated regarding when it is safe to stimulate their loved one.
When the ICP is unstable, maintaining a quiet environment and minimizing stimulation
is essential to the patient’s care.
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Case Study 1
Johnny B. a 22 year-old motocross professional was competing in a practice race when
his bike had a malfunction. Johnny flew off the bike and onto the track. He is
unconscious at the scene. Upon arrival to the trauma center, he has a decreased level
of consciousness, his blood pressure is 180/90, HR 50 and his respiratory rate is 14.
Opening pressures were 18 and his mean arterial pressure was 92. What is his
cerebral perfusion pressure?
CPP is 74 which is low normal.
Based on this CPP, ICP and arterial pressure, what treatment do you anticipate?
Place HOB up 30-45 degrees, whichever is most appropriate to his condition, assure
that his head and neck are in a midline position and not extended or flexed and maintain
a quiet environment.
Johnny’s family and friends are anxious to see him; what will you educate them
on?
Acquaint them with the monitoring systems, what elevated ICP means and how it is
treated and how to keep stimulation to a minimum.
As Johnny progresses, his GCS score rises to 13 and his ICP is 10-12. You
determine he is Improving or deteriorating?
Improving
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Case Study 2
Marybeth was in a car accident as an unrestrained passenger. Upon impact, she was
ejected.
She has been in the ICU for the past 3 days when her ICP is sustained at 24 and her
CPP is 50. Her drain is open at 10 and draining.
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Conclusion
Increased ICP or intracranial hypertension is a life threatening condition that must be
treated quickly to reduce the risk of brain injury or death.
Numerous treatment modalities are available for the healthcare worker. Knowing and
using these modalities increases the probability of positive patient outcomes. Finding
the fine line between normal hemodynamics, effective cerebral perfusion pressure, and
ICP management is essential in caring for these patients.
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References
At the time this course was constructed all URL's in the reference list were current and
accessible. rn.com. is committed to providing healthcare professionals with the most up to date
information available.
Bone, I. & Lindsay, K. (1997). Neurology and Neurosurgery Illustrated. (3rd ed.) Elsevier:
Atlanta.
Copstead, L., & Banasik, J. (2005). Pathophysiology. (3rd Ed.). pp.1099. Saunders: St.
Louis.
Hazinski, M. F., Hedrick, C., & Bruce, D. (1999). Neurologic disorders, Manual of
Pediatric Critical Care, Mosby: St. Louis, p. 371-445
Kocan, M. (2002). Ask The Experts. Critical Care Nurse, 22, pp. 70-73.
Luks, A. (2009). Critical Care Management of the Patient with Elevated Intracranial
Pressure. Critical Care Alert, September 2009, P. 44-48.
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Mayer, S. & Chong, J.Y. (2002). Critical care management of increased intracranial
pressure. Journal of Intensive Care Medicine, 17(2):55-67.
Moore, T. & Woodrow, P. (2009). Nursing Care, Observation, Intervention & Support for
Level 2 Patients. (2nd ed.). New York: Routledge.
Zhong, J., Dujovny, M., Park, H., Perez, E., Perlin, A., & Diaz, F. (2003). Advances in
ICP Monitoring Techniques. Neurological Research, Volume 25, p. 339-350.
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