ICP & SCI

Increased Intracranial Pressure (ICP)

• Purpose of Monitoring ICP: Elevated ICP is a critical concern because it can lead to secondary complications that worsen patient outcomes.

• Normal Range of ICP: Generally accepted range is between 10-15 mmHg. If ICP is 9, no intervention is typically needed.

• Interventions for High ICP: Start interventions when ICP exceeds 20 mmHg for 20 minutes or longer to avoid herniation, which is fatal.

Understanding ICP Spikes vs. Sustained Increases

• Spikes vs. Sustained ICP: A brief spike in ICP (e.g., to 35 mmHg when rolling a patient) is less concerning than a sustained increase.

Manifestations of Increased ICP

• Early Manifestations (in Green):

  • Declining Level of Consciousness (LoC)

  • Restlessness

  • Irritability

  • Confusion

  • Headache

  • Unilateral weakness

  • Pupil changes

• Late Manifestations (in Blue):

  • Severe headache

  • Deterioration of LOC to coma

  • Erratic respiratory rate (apnea or hyperventilation)

  • Tachycardia

  • Hypotension (rapid, thready pulse)

  • Hyperthermia

  • Projectile vomiting

  • Loss of corneal, cough, and gag reflexes

  • Posturing, seizures

  • Fixed pupils (non-reactive)

  • Cushing's Triad: Hypertension with widened pulse pressure, bradycardia, and bradypnea.

Monro-Kellie Hypothesis

• Cranial Volume: Fixed volume in the cranial cavity comprising brain, blood, and cerebrospinal fluid (CSF). An increase in any component requires a compensatory decrease in others to maintain balance.

• Consequences of Imbalance: Increased blood volume (e.g., bleeding) leads to reduced space for brain and CSF, resulting in increased ICP.

Diagnostics and Monitoring Techniques

• Neuro Assessment: Regular neuro assessment, ICP monitoring, can include arterial lines for hemodynamic monitoring.

• ICP Monitoring Methods: Common methods include a bolt or external ventricular drain (EDD).

• Normal ICP Values: Remember, aim for ICP readings ideally below 20 mmHg.

Cerebral Edema and ICP

• Effects of Cerebral Edema: Increases capillary pressure and leakage contributing to elevated ICP. Increased pressure compresses blood vessels leading to ischemia, which prompts autoregulation (vasodilation) and further elevates ICP.

• Role of CO2: High CO2 causes vasodilation (increased ICP) while low CO2 leads to vasoconstriction (decreased blood flow).

Treatments for Elevated ICP

• Basic Nursing Interventions:

  • Elevate head of the bed to 30 degrees for improved venous outflow.

  • Maintain midline positioning to prevent venous outflow obstruction.

  • Monitor and control patient temperature, as extremes can increase ICP.

  • Create a low-stimulation environment to reduce ICP.

  • Limit suctioning to 10 seconds to mitigate ICP spikes.

  • Use Mannitol to draw fluid out of the brain for immediate ICP reduction and monitor urine output as it can also lead to hypotension.

Spinal Cord Injury Overview

• Classification of Spinal Cord Injuries:

  • Complete: No function below injury level.

  • Incomplete: Some function below injury level.

• Causes of Injuries:

  • Examples include hyperflexion, hyperextension, axial loading, and penetrating injuries.

Assessment and Interventions for Spinal Cord Injury

• Primary Assessments: Always assess the respiratory system, particularly in cervical injuries due to impacts on the phrenic nerve leading to respiratory failure.

• Monitoring: Motor function, sensory function, bowel and bladder control, and vital signs. Perform ongoing neurological assessments including GCS.

• Respiratory Management: Monitor respiratory function closely; intubation may be required. Prevent atelectasis through incentives and ventilation support.

Complications of Spinal Cord Injuries

• Neurogenic Shock: Results from loss of sympathetic control, leading to hypotension and bradycardia; can last weeks without full recovery.

• Autonomic Dysreflexia: An exaggerated sympathetic response due to a noxious stimulus below injury, resulting in hypertension and potential organ damage.

Autonomic Dysreflexia Symptoms and Management

• Symptoms: Severe headache, hypertension, bradycardia, nasal congestion, vomiting, and paleness below injury.

• Management:

  • Sit the patient up to decrease BP.

  • Look for and treat the underlying cause, such as a kinked catheter or fecal impaction.

  • Call for provider assistance if symptoms persist.

Conclusion

• Recognizing and addressing increased ICP and spinal cord complications is crucial to patient survival and recovery. Utilize appropriate assessments, interventions, and communication with the healthcare team to optimize outcomes.