Topic 8: ICP

5-15

what is the normal ICP

• hemorrhage

• stroke

• hypo/hyperkalemia

• increased arterial/venous pressures

• increased intrabdominal/intrathoracic pressures: bloating, distention, sneezing, coughing

• posture with head down

• fever

• increased CO2

what are common causes of increased ICP

herniation

what is a complication of increased ICP

60-100 mmHG

what is normal cerebral perfusion pressure

ischemia and neuronal death

what occurs if cerebral perfusion pressure is less than 50 mmHG

incompatible with life

what occurs if cerebral perfusion pressure is less than 30

cerebral edema

increased intravascular fluid in the brain that increases ICP; can be vasogenic, cytotoxic, or interstitial

• altered LOC

• HA that is continuous and worse in the morning

• changes in VS

• Cushing’s triad

  • MEDICAL EMERGENCY

• increased temp

• CN dysfunction

  • fixed, U/L, dilated pupil → MEDICAL EMERGENCY

  • diplopia, blurred vision, EOM changes

  • sluggish

• decrease in motor function with posturing

  • projectile vomiting not preceded by nausea

what are the S/S of increased ICP

Glasgow Coma Scale (GCS)

part of the disability assessment that looks at eye opening, verbal response and motor response; ranges from 3-15

intubate

what should you do if GCS is less than 8

lumbar puncture due to risk of herniation

what diagnostic test should you not do if increased ICP is confirmed/suspected

ventriculostomy

what is the gold standard ICP monitoring device in which a catheter is inserted into the lateral ventricles and couples to an external transducer and directly measures pressure within the ventricles and facilitates removal or sampling of CSF and allows for intraventricular drug admin (chemo)

• monitor O2 and CO2

• mechanical ventilation if needed

• limit suctioning (increases ICP)

• meds:

  • mannitol

  • hypertonic saline

  • keppra

  • corticosteroids

  • antipyretics

  • sedatives/barbiturates

• daily weights and electrolyte monitoring

• monitor for DI and SIADH

• keep HOB elevated and midline, avoid extreme neck flexion

• turn slowly

• prevent pain/discomfort

• avoid hip flexion

• quiet, non stimulating environment

what does management for increased ICP include

mannitol (Osmitrol)

diuretic used for increased ICP that draws fluid out of the brain into the blood to encourage it to leave through the kidneys; monitor for fluid/electrolyte imbalances

0.9% NS

what type of fluids are preferred for increased ICP

keppra

antiseizure med used to prevent grand mal seizures which is a risk associated with increased ICP

dexamethasone (Decadron)

A corticosteroid that is very sensitive to brain tissue and used to treat edema; educate that it may cause hyperglycemia nd immunosuppression

propofol, dexmedetomidine, benzos

what sedatives/barbiturates are used for anxiety to help prevent increasing ICP

falls forward

what is the MCC of head injuries

scalp laceration

external head trauma that can cause profuse bleeding due to the vascularity of the structure so risk of blood loss and infection

• infection (increased temp)

• hematoma

• tissue damage

• rhinorrhea

what are the complications of skull fractures

raccoon eyes and battle sign

what is an expected finding with a basilar skull fracture

raccoon eyes

periorbital edema and ecchymosis that is a sign of a skull fracture

battle sign

bruises behind the ear (postauricular ecchymosis) that is a sign of a skull fracture 

• halo sign: creates a ring around the fluid on the gauze with blood in the middle

• positive for glucose

what can indicate the rhinorrhea is CSF fluid

concussion

sudden, transient mechanical injury that may cause a brief disruption of LOC, retrograde amnesia, HA, and postconcussion syndrome

• persistent HA that lasts 4-6 weeks and NOTHING takes away the pain

• lethargy

• personality/behavioral change

• shortened attention span

• decreased short term memory

• changes in intellectual ability

what are the S/S of post concussion syndrome

diffuse axonal injury (DAI)

widespread axonal damage that causes decreased LOC, increased ICP, decortication/decerebration, and global cerebral edema

lacerations

tearing of brain tissue with depressed and open fractures and penetrating injury that can cause subarachnoid and intraventricular hemorrhage

contusion

bruising of the brain tissue that is associated with a closed head injury

coup

the primary injury when the head strokes forward and the brain hits the skull

countercoup

the second impact that occurs when the brain strikes the skull surface opposite of the site of impact

epidural hematoma

bleeding between the dura and inner surface of the skull that is a neuro emergency due to a sudden increase in ICP

• initial periods of unconsciousness or a brief lucid interval followed by a decrease in LOC

• HA

• N/V

what are the S/S of an epidural hematoma

subdural hematoma

bleeding between the dura mater and arachnoid mater that can be acute or chronic and has S/S of increased ICP

surgical evacuation

what is the treatment for subdural and epidural hematomas

CT

this diagnostic is best to determine head truam and gives rapid diagnosis = rapid interventions

• CAB

• stabilize C spine

• O2

• 2 large bore IVs

• intubate if GCS < 8 or gag reflex is impaired/absent

• remove clothing

• maintain temp

• give fluids cautiously

what are the interventions for head traumas

• what happened?

• are you on any anticoagulants?

• do you use drugs and alcohol?

• do you have a HA and if so is it getting worse? 

what are good assessment questions to ask if someone has experienced a head trauma

• lay them flat

• loose collection pad over nose/ear (mustache dressing)

• do not sneeze/blow nose (increases ICP)

• no NG tube or nasotracheal suctioning (increase ICP)

what are interventions if someone is leaking CSF

• dull, constant HA that is worse at night and

• seizures

• N/V

• memory, mood, and personality changes

• increased ICP and hydrocephalus cause increased S/S and eventually lead to death

what are S/S of a brain tumor

• removal/debulking of tumor

• prevent/manage ICP

  • frequent neuro/VS checks

  • monitor fluids and electrolytes

  • pain control

  • if anterior elevate HOB to 30, if posterior flat to slight elevation

  • if they got a craniectomy, do not place on that side

  • monitor for bleeding and CSF

• ventricular shunts: watch for increased ICP

• corticosteroids to reduce inflammation

• chemo

• keppra

• antiemetics 

what does care for a brain tumor include