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
 Brain Tumor

Decrease Cerebral Blood Flow

Ischemia and Cell Death Early Cerebral Ischemia

Vasomotor Stimulation
(brainstem)

Increase Systemic Pressure

(s/sx slow pulse, cheyne-stokes
resp.,elevated temp.)

Increase ICP
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
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
 Measure ICP

Maintain CPP>70 mm Hg
Management of
Raised ICP Raised ICP>25mm Hg

First Line Ventricular Drain

Rx
Raised ICP>25mm Hg CT

Normal Vent/Oxygenation
Mannitol
Sedation
 Maintain CPP>70 mm Hg

Management of Raised ICP>25mm Hg

Raised ICP
Furosemide
Chemical Paralysis
Second Line CSF Removal
Vasopressor
Rx

Raised ICP>25mm Hg

Barbiturates
Hyperventilation
Monitor SjO2
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