INTRACRANIAL PRESSURE

Jum’at, 10 Maret 2017

Anwar Wardy
Sitti Airiza Jenie
Robiah Khairani Hasibuan

PROGRAM STUDI PENDIDIKAN DOKTER

FAKULTAS KEDOKTERAN DAN KESEHATAN
UNIVERSITAS MUHAMMADIYAH JAKARTA
 Intracranial Pressure
What does it entail?
• Compensatory mechanisms with the cranium maintain intracranial
pressure at between 0 - 15 mm hg.

• Contents of skull: Brain, blood, cerebrospinal fluid CSF

• As volume of one component increases,

volume of the others compensate to
maintain intracranial (ICP) pressure & not to
have any neurological changes occur.

anwar wardy w FKK UMJ

 Intracranial Pressure
Monro-Kellie Hypothesis for ICP
• Contents of skull: Brain, blood, cerebrospinal fluid CSF Balance
between these 3 compartments maintains the pressure within the
cranium.

• Monro-Kellie Hypothesis for ICP

– Because the bony skull cannot expand, when 1 of the 3 compartments
expands, the other 2 must compensate by decreasing in volume in order
for the total brain volume & pressure to remain constant.
– As volume of one component increases,
volume of the others compensate
to maintain intracranial (ICP) pressure
& not to have any neurological
changes
anwar wardy w occur. FKK UMJ
 Intracranial Pressure
• As incracanial mass enlarges, compensation occurs

• 1st Compensation is Displacement of CSF into the spinal canal

• 2nd Compensation is Reduction of blood volume in the brain

• 3rd Compensation & most lethal is

– Displacement of brain tissue (herniation)

– (see next slide)

anwar wardy w FKK UMJ

 Intracranial Pressure

• As incracanial mass enlarges, compensation occurs

• 1)1st form of Compensation is Displacement of CSF into the spinal
canal
• Ability of brain to adapt to >pressure without >ICP is called compliance.
• 2) 2nd form of Compensation is Reduction of blood volume in the
brain
• This stage alters cerebral metabolism, eventually leading to brain tissue
hypoxia & areas of brain tissue ischemia
• 3) 3rd & last form of Compensation & most lethal is
– Displacement of brain tissue across the tentorium, under the falx cerebri,
or thru the foramen magnum into the spinal canal.
• This process is called herniation & often results in death from brain stem
anwar compression
wardy w FKK UMJ
 Intracranial Pressure
Neuro Changes
• Neurological changes occur because of cellular hypoxia
& displacement of the brain.

• Neurons are compressed, especially in the brain stem due

to:
(1) > blood volume from vascular vasodilatation
(2) >volume of brain tissue from edema, infection,
tumor, or hemorrhage
(3) >CSF from overproduction, <reabsorption or
interruption of CSF circulation

anwar wardy w FKK UMJ

 Increased ICP
• >ICP reduces cerebral blood • 2 Stages of Cerebral
flow & results in ischemia adjustment:
3-5 minutes with (1) Compensation-
irreversible brain damage maintains cerebral perfusion
pressure
• Early Stages
• (2)Decompensation
Attempt to maintain
Change in LOC
cerebral blood flow Bradycardia
Widening pulse pressure
Slow bounding pulse & Resp changes
resp irregularities
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 ICP Assessment - continued

• (4)Increased body temp • (7)Vital Signs

Cushings triad-late
>BP, wide pulse pressure,
• (5)Hypothalmus pressure
bradycardia

• (6)Seizure Activity

• (8) Respiratory changes-

Cheyne stoking projectile
vomiting later
• see next slides for details of
Assessment of ICP
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 Assessment of ICP
• (1) Change in LOC
• May be subtle such as
– A flattening of affect
– Change in orientation
– Decrease in level of attention
– Dramatic - coma

• Changes in LOC are due to impaired cerebral blood flow,

which affects the cells of the cerebral cortes & the RAS
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 Assessment of ICP
• (2) Changes in Vital signs
• Late Sign is Cushing Triad (see next slide example)
– (1) Increasing systolic pressure (widening pulse pressure)
– (2) Bradycardia with full & bounding pulse
– (3) Irregular resp pattern

• Changes in vital signs are due to increasing pressure on the pons,

medulla, hypothalamus, and thalamus.

• Bradycardia may be due to pressure & stimulation of CNX Vagus

• A changes
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in body temp may also be noted
 Increased ICP
Cushings Triad
• (1) Systolic Hypertension
• (2) Widening Pulse Pressure
• (3) Bradycardia
• Ex. 9am 11am 1pm
120/80 135/70 150/60
<pulse <<pulse <<<pulse
• <LOC <<LOC <<<LOC

• Associated Signs:
Decorticate or
Decerebrate Posturing
anwar wardy w
Changes in RespiratoryFKKPattern
UMJ
 ABNORMAL MOTOR RESPONSES
(a) Decorticate -Flexor posturing *to the cord
(b) Extensor Posturing (Decerebrate)
© Combination of a&b (d) Flaccid

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 Assessment of ICP
• (3) Occular signs
• Compression of the oculomotor nerve (CN III) results in
– Dilation of the ipsilateral pupil
– Sluggish or no response to light
– Inability to move the eye upward
– Ptosis of the eyelid

• These signs can be due to a shifting of the brain from midline,

which compresses the trunk of the cranial nerve, paralyzing the
pupil sphincter.
• A fixed, unilaterally dilated pupil is a neruo emergency that
anwar wardy w FKK UMJ
indicates transtentorial herniation of the brain.
 Assessment of ICP
• (3) Occular signs - continued
• Other cranial nerves may also be affected, such as
• Optic (CN II)
• Trochlear (CN IV)
• Abducens (CN VI)
• Signs of dysfunction of these cranial nerves include
– Blurred vision
– Diplopia
– Changes in extraocular eye movement
• Papilledema, of optic disk seen on retinal exam, is also seen & is a
nonspecific sign that is associated with long standing >ICP
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 Assessment of ICP
• (4)Decreased in motor function
• As ICP continues to rise, the pt changes in motor ability

• A contralateral hemiparesis or hemiplegia may be seen, depending

on location of the source of the >ICP

• If painful stimuli to elicit a motor response is used, pt may exhibit a

a localization to the stimuli or a withdrawal from it. Highest level of
motor response is to push stimulus away.

• Decorticate (Flexor) & Decerebrate (Extensor) posturing may also

be anwar
elicited by noxious stimuli FKK UMJ
wardy w
 Assessment of ICP
• (5) Headache
• Although the brain itself is insensitive to pain, compression of other
intracranial structures such as the walls of arteries & veins & the
cranial nerves can produce headache.
• Headache is often continuous but worse in the morning. Can
subside later on in the day.
• Straining or movement may accentuate the pain
• (6) Vomiting
• Vomiting, usually not preceded by nausea, is often a nonspecific
sign of >ICP.
– Called unexpected vomiting & is due to pressure changes in
the wardy
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w FKK UMJ
 Early S/S ICP
• S/S of >ICP:
• <LOC-Confusion,difficulty rousing,Restlessness
• Changes in pupil size or reaction to light-dilation & unresp to light
• Muscle weakness-hemiplegia or paraplegia
• Decrease in Glasgow coma scale
• changes in speech, pupil reaction, motor or sensory ability, cardiac
rate & rhythm
• HA, N/V, blurred or double vision (diplopia)
• Papilledema (swelling of optic nerve) causes sluggish or no pupillary
response to light via ophth exam

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 Late S/S ICP
• Cushing’s triad-> systolic BP with widened pulse pressure
& bradycardia

• Resp-cheyne-Stokes to hyperventiliation to apneustic

breathing(prolonged inspiration followed by expiration
apnea) & ataxic breathing (assoc with lesion in medullary
resp center & characterized by series of inspirations &
expirations)as ICP>

• Hyperthermia when hypothalamus is 1st affected by >ICP

followed
anwar wardy wby hypothermia as
FKKICP>more
UMJ
 Brain Stem Pressure

• Cushings Triad
– Systolic BP Increases
– Widening Pulse Pressure
– Slowing Pulse

• Respiratory Irregularities (Cheyne-Stokes)

Shallow rapid respirations with periods of
apnea

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 Increased ICP
Herniation
• Results from >ICP • Signs
• Portions of brain tissue shifts & • Ipsilateral pupil dilation
interferes with blood supply (one pupil dilated)
• Results from excessive >ICP • Decreased LOC
• Pressure builds in cranial vault. • Resp Changes
Brain tissue presses down on • Contralateral hemiplegia
brain stem. (originating in or affecting
• >Brain stem pressure results in the opposite side of the
cessation of blood flow to body)
brain, causing irreversible brain
anoxia & brain death
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 Treatment of ICP

• Medical
• Oxygen-to maintain cerebral perfusion
• Oral suctioning-Never thru nose on a head injury
possible CSF leakage

• Surgical
• Decompression-remove a bone flap to allow for expansion
of brain
• Remove a tumor, hematoma, or abscess
• Drain excess CSF from ventricles

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 Treatment of ICP

• Pharmacological
• Steroids to < cerebral edema
• antacids or histamine 2 antagonists to
< S/E of steroids,
< stress-induced gastric acidity
• Osmostic diuretics to rapidly reduce fluid in the brain tissue
• Muscle relaxants
• Sedatives & Barbiturates
• Muscle paralyzing agents
• antipyretics & anticonvulsant
• **No
anwarOpiates**they
wardy w decrease LOC
FKK UMJ
 Increased Intracranial Pressure ICP

• ICP is the pressure exerted in the cranium by its

contents:

(a) brain tissue

(b)Intracranial blood volumn
(c) CerebroSpinal Fluid CSF

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 Increased Intracranial Pressure ICP
• Causes
• Destructive expanding lesion-
(a)Tumors
(b)Hematoma
© Hemorrhag
(d) cerebral infarct
• (e) hydrocephalus (obstruction to CSF outflow)
• (f) Abscess from infection
(g) ingested toxin
(h)Edema from trauma

• anwar
Normal
wardy w ICP <15mm/Hg ICP>15
FKK UMJ considered elevated &
potentially life threatening
 Increased Intracranial Pressure
Risk Factors (Brain RAS-Reticular System)

• (1)Epidural, subdural, subarachnoid, or

intracerebral bleeding
(2) Swelling of brain
(3) Tumors or other lesions in brain
(4) Inflammatory processes in brain
(5) >cerebral blood flow or impairment of
cerebral venous flow
(6) >production, <absorption, or blockage of CSF flow
(7) vasodilation from >Co2 or <O2
(8)Uncompensated hypertension
(9) > intrathoracic pressure
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 Interventions Nursing Care
• Ensure adequate
oxyenation
* Pulse oximeter
*02
*Ventilation
• Promote venous drainage
*>HOV
*Keep aligned, no
hip/neckflexion
*CSF drainage-venting
• Maintain Normal
Temperature
*Cooling blanket
*No shivering-thorazine
*No oral temps
• Maintain normal BP
• Controlled
hyperventilation
• Protect against injury

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 Interventions Nursing Care -continued
• Cerebral Edema
*Treat with Mannitol
(Osmotic diuretic to rapidly reduce fluid in brain tissue)
Always give with filter [to prevent crystals entering blood
steam] & watch for s/s of CHF after mannitol admin

• Hypoxia *Maintain 02

• Hyperventilation causes vasoconstriction decreases blood flow

anwar wardy w FKK UMJ

 Interventions Nursing Care -continued
• Suction as needed & maintain head alignment HOB>30 degrees

• Laxative to prevent valsalva (any forced expiratory effort against a

closed airway or straining from pushing or pulling forcefully as in
struggling)

– Valsalva (CNX-Vagus) causes >intrathoracic pressure, slowing of

pulse, slow venous return from the brain, <return of blood to the
heart, >venous pressure.

anwar wardy w FKK UMJ

Valsalva manuever-any forced expiratory effort against a closed airway, such as when
a pt hold the breath & tightens the muscles in a strenuous effort to move a heavy object
or to change position in bed.

• On relaxing after each muscular effort

• Most healthy people perform Valsalva
manuevers during normal daily
activities without any injurious
consequences, but such efforts are
dangerous for many patients with
cardiovascular disease, especially if
they become dehydrated, increasing
the viscosity of their blood & the
attendant risk of blood clotting.
with held breath, the blood of such pt
rushes to the heart, often overloading
the cardiac system * causing cardiac
arrest.
• Orthopedic pt often use a Valsalva
manuever in changing their position in
bed with the aid of an overhead
trapeze bar.

• Constipation increases the risk of • Patients who may be endanged by

cardiovascular trauma in such pt,
especially if they perform a Valsalva
manuever in trying to move their
bowels.
anwar wardy w
performing a Valsalva manuever are
commonly instructed to exhale instead
of holding their breath when they
move. The exhalation decreases the
FKK UMJ risk of cardiovascular trauma.
 Meds for ICP
• (1)Osmotic Diuretics
Mannitol - Action- used to manage cerebral edema associated
with ICP by causing fluid to be pulled from within the cell into the
hyperosmolar serum, <intracranial or intraocular pressure, excessive
loss of water and electrolytes.
In other words, brain tissue is relieved of excess fluid (edema) &
therefore cerebral / brain tissue edema decreased

• this is an emergency drug

• Nursing measures- vital signs and neuro checks q 15 minutes,

• I&O q 1 hour should be 30 – 50 ml per hour

Assess urinary output- urine
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output should be greatly increased
FKK UMJ
Urine output will be greater than fluid intake
 Meds for ICP
• (2)Corticosteroids - Decadron dexamethasone
Taper off Assess for GI bleed (monitor H&H, stool
for occult blood, VS with <BP & increased pulse) & Bld Gas>
• Action-anti-inflammatory or immunosuppressive, relieves
cerebral edema, <inflammation & immune response, reverses
shock

• Nursing measures-
• *Do not discontinue, taper, may cause adrenal suppression- can
be life threatening
*Administer in a.m. to coincide with body’s normal
secretion of cortisol
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 Meds for ICP
• (2)Corticosteroids - Decadron Taper off, do not abruptly
D/C

• Nursing measures- *Do not discontinue, taper, may cause

adrenal suppression- can be life threatening
*Administer in a.m. to coincide with body’s normal
secretion of cortisol

• *Administer with meals if possible to <GI S/S

• *May mask symptoms of infection, monitor >temp, WBC even

after withdrawal of med secondary to drug masking infection
• *Discuss
anwar wardy wbody image - wt gain,easy
FKK UMJ bruising
 Meds for ICP
• Cushing’s syndrome-metaolic disorder resulting from
chronic and excessive production of cortisol by adrenal cortex
OR by admin of glucocorticoids in large doses for several
weeks or longer

• When occuring spontaneously, the syndrome represents a

failure in body ability to regulate the secretion of cortisol or
adrenocorticotropic hormone ACTH.

Normally cortisol is produced only in response to ACTH,

And ACTH is not secreted in presence of high levels of
cortisol.
anwar wardy w FKK UMJ
 Meds for ICP
• (3)Neuromuscular Blockers Pavulon
Action & Indications:
(1)Adjunct to anesthesia to induce skeletal muscle relaxation
(2) to facilitate intubation;
(3) to lessen muscle contractions in pharmacologically or electrically
induced seizures,
(4) to assist with mechanical ventilation.
Dose: Depends on anesthetic used, individual needs, & response. Doses have to
be adjusted.

**Administer sedatives or general anesthetics before

neurmuscular blockers, as orders. Neuromuscular blockers don’t obtund
consciouseness or alter pain threshold.

• Have emergency respiratory support equipment immediately avail

(endotracheal equipment, ventilator, oxygen, atropine, epinephrine).
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 Meds ICP
• (4) AntiHTN-Nipride
(a)Lowers BP quickly in HTN emergency
(b) produces controlled hypotension during anestheaia
(c) reduces preload & afterload in cardiac pumpfailure or
cardiogenic (may be used with or without dopamine)
Nipride sensitive to light, wrap IV solution in foil, infuse
Nipride IVPB thru peripheral line w/o other meds.
• Used in extreme caution in pt with >ICP

• [Dopamine-vasopressor ] Dopamine Used:

(a) treat shock & correct hemodynamic imbalances
(b) improve perfusion to vital organs
(c)
anwar Increase
wardy w cardiac outputFKK UMJ
(d) correct hypotension
 Meds for ICP

• (5)Antipyretics

• (6)Anticonvulsants Valium Dilantin Phenobarb

• (7)High dose Barbiturate/Coma

< BMR to Decrease ICP

• (8)Vasoconstrictors To maintain BP & prevent

ischemia during hypotensive episodes
anwar wardy w FKK UMJ
 Treatment for ICP
• Respiratory support • Check for
Oxygen Cerebrospinal Fluid
Airway • Check for Seizures
Support • Treatment for Muscle
Hyperventilatioin Paralysis & Sedation
• Osmotic Diuretic
• Corticosteriods
• BP Control
• Seizure Control
• Fluid Restriction
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 Management of
Acute Increased ICP
• Avoid
• HOB up to <brain venous
hydrostatic pressure
• 1) Rotation or flexion of
neck
• Fluid restriction
– Compression or distortion of
• Maintain Temp
jugular veins >ICP
• Medication
• 2) Extreme hip flexion
– Steroids (decadron)
– >intra-abdominal & intra
– Mannitol
throacic pressure can >ICP
– Hypertonic IV
• 3) Valsalva maneuver
– Sedative
• CNX (Vagus) will >ICP
– Ventilator
anwar wardy w FKK UMJ
 Management of Acute Increased ICP
Emergency- Must relieve ICP
• 1) Decrease edema
• 2) Decrease CSF volume or • These goals accomplished by
• 3) Decrease cerebral blood – Admin osmotic diuretics
volume while maintaining – Admin corticosteroids
cerebral perfusion. – Restrict fluids
• Reduce Metabolism Demands – Drianing CSF
• Pavulon – Control fever
• Barbiturates – Maintain systolic BP & 02
– Cannot move
– Decrease cellular metabolic
– Decrease metabolic demands
demand
results in decrease cerebral 02
demand
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 Goals for Pt with >ICP
• Hyperventilation with 100%
oxygen before suctioning each time.
• Attain fluid balance
– Hypoxia-poor 02 leads to
cerebral ischemia & edema (a) fluid restriction
(b) Check for s/s dehydration
• Suction with proper size catheter-
insertion of catheter no more than • Mannitol -used but monitor for S/E
10 seconds maximum CHF or pul edema

• ICP should not rise >25 Keep • Prevent infection

environment quiet & avoid abd
distention

• Attain normal resp rate

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 Goals for Pt with >ICP
• Monitor for
– Fever
– chills
– nuchal (neck) rigidity
– > or persistent headache.
• Lower body temp will
– <cerebral edema • Fever will
– <02 & metablic demands of – > cerebral metabolism &
brain – >cerebral edema
– protect brain from continued
ischemia.

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 Goals for Pt with >ICP
•
• Manage potential (1) Ventricular Cath
complication-Herniation Monitoring
– Monitor for >BP, <HR,
– (a) Allows ventricles to drain
change in pupils
– (b) Can give meds, dx tests
– © Complication-infection,
• Measures CSF within meningitis, ventricular
– lateral ventricle collapse, occlusion
– subarachnoid space
– & epidural

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 ICP-Nursing Interventions
• Elevate HOB to semi-Fowler’s to <brain hydrostatic pressure
• Never place in Trendelenburg
• V/S and neuro checks q15 minutes
• Prevent aspiration
• Place Pt on Side
• Maintain airway- O2
• Observe pupillary response ( usually unequal and may not react to
light)
• Report changes in LOC immediately
• Seizure precautions
• Provide care for Coma Pt
• Monitor IV fluids– Do not overhydrate
• NPO or fluid limited by M.D.
• I &anwar wardy w
O q1h FKK UMJ
 Nsg Dx ICP:
Altered Tissue Perfusion (Cerebral )
R/T >ICP
• Goal: the ICP is between 1-
15mm Hg & the
GCS is >8 • Avoid extreme flexion of hip
• Assessment Data: <LOC, • Keep pt quiet
Sluggish pupil response, • Admin reduced fluid volume
Papilledema, Posturing evenely over 24 hr
• Planning: Keep HOB elevated • Mechanical ventilation as
slightly & Pt head straight to ordered
keep ICP down (for those with • Assess bowel founds & bowel
basal skull fx keep HOB flat) pattern to ensure
• Limit movement NO valsalva maneuvers
(will >ICP) CNX stimulation
(Vagus) will>ICP & <BP
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 TERIMA KASIH

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