ICP, TBI Stroke

Increased Intracranial Pressure (ICP)

Definition

• Increased Intracranial Pressure (ICP): A condition characterized by elevated pressure inside the skull due to the constrained volume of components within the skull, which include the brain, blood, and cerebrospinal fluid (CSF). Positive changes in one of these components require compensatory adjustments in others to maintain normal intracranial pressure.

  • Closed Skull Environment: The skull is a closed box; if one component increases, the others must decrease, or ICP rises. Excessive pressure can compromise brain tissue, leading to:

  • Decreased Level of Consciousness (LOC)

  • Brain damage

  • Potentially, death

Causes of Increased ICP

1. Infection

2. Increased cerebrospinal fluid (CSF)

3. Head injury or trauma

4. Brain tumor or bleeding

5. Stroke

Signs & Symptoms of Increased ICP

• Early Signs:

  • Decreased Level of Consciousness (LOC)

  • Headache

  • Vomiting (without nausea)

  • Blurred vision

  • Unequal pupils

  • Rising temperature

• Late Signs:

  • Decorticate and Decerebrate Posturing

  • Cushing's Triad:

  • Increased systolic blood pressure

  • Decreased heart rate

  • Irregular respirations

Nursing Interventions for Increased ICP

• Elevate the head of the bed (HOB) to 30°.

• Maintain neck alignment; avoid bending or twisting.

• Limit suctioning and coughing.

• Ensure a calm environment.

• Monitor neurological status closely.

Traumatic Brain Injury (TBI)

Definition

• Traumatic Brain Injury (TBI): Injury to the brain caused by an external force, resulting in temporary or permanent changes to brain functions. Typically occurs due to:

  • Motor vehicle collisions (MVC)

  • Falls

  • Assaults

  • Sports-related injuries

Types of TBI

1. Closed (Non-Penetrating)

• Description: Brain moves inside an intact skull leading to bruising and tearing.

• Example: Whiplash, falls.

2. Open (Penetrating)

• Description: An object breaks the skull and enters the brain.

• Example: Gunshot wound.

3. Acceleration Injuries

• Definition: A moving object strikes a still head (e.g. being hit with a baseball bat).

4. Deceleration Injuries

• Definition: A moving head strikes a stationary object (e.g., a fall).

5. Acceleration-Deceleration Combos

• Definition: Combination of both acceleration and deceleration injuries (e.g., soccer-related injuries where the head hits the ground).

6. Rotational Injuries

• Definition: The brain twists inside the skull, causing shearing and tearing (e.g., side-impact car crashes).

Types of TBI Symptoms

1. Concussion (Mild)

• Symptoms: Brief loss of consciousness to none, headache, dizziness, nausea/vomiting, memory loss before or after the injury.

• Not visible on CT or MRI.

2. Contusion (Bruised Brain)

• Symptoms depend on the part of the brain injured, can include decreased LOC, abnormal pupils, motor changes, potentially brainstem contusion.

3. Hematoma (Bleed)

• Subdural Hematoma (Venous): Can be acute with symptoms within 24 hours (e.g., one-sided paralysis, weakness) or chronic developing over weeks/months (e.g., lethargy, irritability).

• Epidural Hematoma (Arterial): Associated with skull fractures, rapid deterioration, requires immediate surgery.

Diagnostic Tests for TBI

1. CT Scan: Fast and accessible.

2. MRI: Used later to identify specific damage to brain tissue.

3. Neuropsychological Testing: Evaluates cognitive functions such as memory, judgment, learning, and concentration.

Common Symptoms of TBI

• Headache, dizziness

• Confusion, feeling foggy

• Nausea or vomiting

• Sensitivity to light or noise

• Short-term memory loss

Treatment for TBI

1. Barbiturate Coma: Used to manage ICP, maintaining normal temperature and blood pressure (BP).

2. CSF Drainage: To alleviate pressure.

3. Mannitol: An osmotic diuretic to decrease ICP.

4. Mechanical Hyperventilation: To control ICP.

Nursing Treatment and Education

• Rest the brain and body.

• Monitor for worsening symptoms.

• Avoid sedatives or alcohol.

• Educate family about signs of increased ICP.

• Advise against sports or screens until cleared, as it can mask symptoms and depress the central nervous system (CNS).

• Regularly monitor ICP to notice changes promptly.

Complications of TBI

• Brain herniation

• Labile vital signs

• Diabetes insipidus

• Post-concussion syndrome or PTSD

• Acute hydrocephalus

• Cognitive and personality changes.

Brain Attack / Stroke

Definition

• Brain Attack/Stroke: A critical condition where blood flow to the brain is disrupted, depriving the brain cells of oxygen and glucose, leading to cell death. Early recognition significantly improves outcomes.

Transient Ischemic Attack (TIA)

Definition

• TIA: A temporary blockage of blood flow to the brain with symptoms that last from minutes to hours, usually resolving completely. It is considered a warning sign for potential stroke.

Causes and Risk Factors for Stroke

Modifiable Factors

• Hypertension

• Diabetes Mellitus

• Hyperlipidemia/High Cholesterol

• Smoking

• Atherosclerosis

• Obesity/Sedentary Lifestyle

Non-Modifiable Factors

• Age

• Gender

• Family History

• Genetics

• Race

Types of Stroke

1. Ischemic Stroke: Blockage of blood flow leading to neuron death. Can be:

   • Thrombotic: A clot forms in a brain artery.

   • Embolic: A clot travels from the heart to the brain.

2. Hemorrhagic Stroke: A rupture of blood vessels causing pressure on brain tissue. Can be:

   • Subarachnoid: Located on the surface of the brain.

   • Intracerebral: Located deeper within brain tissue.

Symptoms of Stroke

• Balance issues

• Eyes: Vision disturbances

• Face: Facial drooping

• Arms: Weakness or numbness

• Speech: Slurred or impaired speaking

• Time: Critical to act quickly, noting different hemisphere effects:

  • Left Hemisphere: Affects language and logic.

  • Right Hemisphere: Affects personality and senses of recklessness.

Nursing Interventions - Acute Care

• ABCs: Focus on Airway, Breathing, Circulation.

  • Maintain oxygen saturation over 94%.

  • Monitor level of consciousness (LOC), vital signs, and heart rhythm.

• Dysphagia Screening: Prevent aspiration risk.

• Prepare for Imaging: To determine the type of stroke.

Medications for Stroke

Nursing Interventions - Ongoing Care

• Prevent complications (DVT, pneumonia, pressure injuries).

• Provide therapy (PT/OT/speech).

• Control blood pressure and blood sugar levels to prevent further damage.

• Administer medications (antiplatelets, anticoagulants, thrombolytics, and statins).

Long Term Effects of Stroke

• Impaired motor function and sensation.

• Difficulty swallowing.

• Bowel and bladder function issues.

• Aphasia.

• Pseudobulbar Affect (PBA).

• Impaired judgment and safety awareness.

• Unilateral neglect.

Surgery for Stroke Prevention

• Carotid Endarterectomy: To remove blockage in the carotid artery.

• Carotid Stenting: To balloon and stent to open the artery, aimed at restoring blood flow and preventing future strokes.