INCREASED INTRACRANIAL PRESSURE

STEPHANIE TALBOT

ACUTE INTRACRANIAL PROBLEMS

Normal ICP=10-15mmHg Factors affecting ICP: - arterial & venous pressure, posture, IAP, blood gases (esp. PaCO2) Initial compensation for IICP:
1. Altered CSF absorption & productiondisplacement CSF down spinal subarachnoid space 2. Displacing of venous blood flow into sinuses, collapse cerebral veins, increasing outflow 3. Distention dura mater & compression of cerebrum if untreated cerebrum herniates into brain stem

ACUTE INTRACRANIAL PROBLEMS

If ICP continues to increase loss of Auto-

regulation DECOMPENSATION
Brain has ability to dilate own vessels to maintain blood flow in response to arterial pressure

Decompensation results tissue hypoxia decreased pH & increased PCO2edemaif untreated herniation into brainstem DEATH

ACUTE INTRACRANIAL PROBLEMS

Blood flows through brain rate 50mL/min/100g tissue Mean arterial pressure (MAP) N=50150mmHg for effective autoregulation to occur Cerebral perfusion pressure(CPP) is the pressure needed to ensure blood flow to brain ( maintain O2 & nutrient delivery) N=60100mmHg

ACUTE INTRACRANIAL PROBLEMS

Once compensatory mechanisms fail, autoregulation is lost increase systemic BP to maintain cerebral brain flow (CBF) decompensation CUSHINGS TRIAD= increased SBP w/ widening pulse pressure, bradycardia w/ full bounding pulse, altered respiratory pattern (cheyne-stokes, ataxia, cluster bx, central neurogenic hyperventilation, apneustic)

ACUTE INTRACRANIAL PROBLEMS

IF BECOME ACUTELY UNCONSCIOUSSUSPECT INCREASED ICP

ACUTE INTRACRANIAL PROBLEMS

IICP *LIFE THREATENING*
Cerebral edema most important factor, results increased tissue volume Can be vasogenic (leaky membranes), Cytotoxic (change cell permeability to Na+-brings water), interstitial (assoc. w/ increased BP)

ACUTE INTRACRANIAL PROBLEMS

Signs & symptoms ICP: 1. Change LOC- sudden unconsciousness, flattening affect, decreased attention 2. Change VS- due to increased P on hypothalamus change in temp (high temp days) without sweating, etc, cushings triad 3. Headache 4. Vomiting- not preceded by vomiting 5. seizures 6. Ocular signs:
Increased size blind spot, Papilledema (edematous optic disk), unilateral dilation pupil (CN III), sluggish pupil,, Ptosis eyelid, CN II,IV, VI: Diplopia, decreased visual acuity, inability move eye up

7.

Decreased motor fxnhemiparesis or hemiplegia decerebate/ decortate posturing

ACUTE INTRACRANIAL PROBLEMS

DIAGNOSTICS: 1. CT scan & MRI- diff conditions that cause IICP 2. Cerebral angiography 3. EEG 4. ICP measure w/ LICOX catheter gold standard- measures P in ventricles PbtO2 *measure P @ end of expiration*, add a 3way stopcock & drain CSFkeep 15cm above ear

ACUTE INTRACRANIAL PROBLEMS

COLLABORATIVE CARE 1. Intubation& ventilation-1st priority maintain oxygenation
HOB 30 deg. w/ neck neutral

6.

2. 3. 4. 5.

ICP monitoring Cerebral oxygenation monitor w/ LICOX Maintain PaO2>100mmHg

ABGs

Maintain fluid balance & osmolality

Maintain systolic arterial P 100-60mmHg, CPP>60mmHg 7. Reduce cerebral metabolismhigh-dose barbiturates 8. Drug therapy: Mannitol, corticosteroids for those w/ brain tumors or bacterial meningitisH2 agonist or PPI 9. Nutrition therapy- w/in 3dys 10. Surgery: craniotomy- burr holes

ASSESSMENT IICP
1. Assess LOC using Glasco Coma Scale
-evals ability to speak, open eyes & follow commands

2. Neuro assessment:
-compare pupil size, shape movement & reactivity (CNIII) -fixed pupil=IICP -Eye movement (CNIII,IV,VI)-turn head side-side-dolls eyes, flex & extend neckeyes move opposite direction -hand grips & ability raise feet off bed

3. VS

ASSESSMENT IICP
Glascow coma scale- 1477- Open eyes, motor response, verbal response, score up to 15, most pts are intubated so it prevents points. Eyes- if spontaneous opening they get 4 down to one if not opening, Verbal- if appropriate they get 5 down to one if not answering at all, Motor- if obedient they get 6 if not down to one, 15 is fully AOx3, <8 = coma generally

NSG INTERVENTION IICP- Goal: maintain patent airway,

maintain ICP w/in normal limits, maintain fluid & e-lytes, no complications

1. Maintain patent airway -HOB 30, log roll w/ elevated 2. NG tube to decompress stomach 3. Admin morphine, sedatives, neuromuscular blocking agents 4. Check ABG- maintain PaO2 & PaCO2 w/ N

5. IV fluids -I/O & daily weight, e-ltyes: serum glucose Na, K, osmolality, UOP (^r/t decreased antidiuretic hormonediabetes insipidus; decreased UOP r/t SIADH dilutional hyponatremia -tx=IV fluids, vasopressin or desmopressin