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Increased Intracranial Pressure
Monro-Kellie hypothesis:becauseof limited space in the skull, anincrease in any one skull componentbrain tissue, blood, or CSFnecessitates a change in the volume ofanother
Compensation to maintain a normalICP of 10 to 0 mm !g is normally
accomplished by shifting or displacingCSF"ith disease or in#ury, ICP may
increaseIncreased ICP decreases cerebral
perfusion, causes ischemia, cell death,
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ICP and CPP
&ormal ICP is 10 to 0 mm!g
CCP $cerebral perfusion pressure% is
closely linked to ICP
CCP ' ()P $mean arterial pressure% * ICP
&ormal CCP is +0 to 100
) CCP of less than 0 results in
permanent neuralgic damage
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-arly Signs of ICP.he earliest sign of increasingICP is a change in /C
Slo2ing of speech and delayin response to verbal
suggestions are other earlyindicators
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3etecting -arly Indications ofIncreasing ICP
3isorientation, restlessness, increasingagitation, increased respiratory e4ort $5ussmaulbreathing%, purposeless movements, andmental confusion
Pupillary changes and impaired e6traocularmovements
"eakness in one e6tremity or on one side of the
body!eadache that is constant, increasing inintensity, and aggravated by movement orstraining
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ther manifestations
include7
8ehavior changes
Sei9ures
&ausea and :omiting/ethargy
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in ICP is a medical
emergency.reatment should
be initiatedimmediately
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"ays to relieve an increase in ICP
3ecrease Cerebral-dema
(annitol
Fluid ;estrictions )ssess 8P, skinturgor, mucousmembranes, urineoutput < osmolality
I: Fluids prescribed* slo2 to moderaterate
ral hygiene b=c ofdehydration
(aintainingCerebral Perfusion
3obutre6
/evophed5eep head in amidline position
)void e6treme hip
>e6ion)void the :alsalvamaneuver
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"ays to relieve an increase in ICP
;educing CSF andIntracranial 8lood
:olume3rain CSF
)septic techni?ueand assess for
signs of infection!yperventilation *as a last resort
Controlling Fever)ntipyretic medications
!ypothermia blanket
)void shivering in the
patient;emoving all bedding overthe patient $e6cept for alight sheet%
@iving cool sponge bathsand an electric fan to
facilitate cooling
(onitor temperaturefre?uently * monitorresponse to therapy and toprevent e6cess decrease in
temperature and shivering
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"ays to relieve an increase in ICP
(aintaining6ygenation
(aintain a patentair2ay
3iscourage coughingand straining
)uscultate lungs everyA hours
(onitor )8@s andPulse o6ymetry
ptimi9e hemoglobinsaturation
;educing (etabolic
3emands!igh doses ofbarbiturates
Paralytics
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3ue to the use of paraly9ing agentspatient 2ill re?uire7
Continuous cardiacmonitoring
-ndotracheal intubation
(echanical ventilation
ICP monitoring
)rterial pressure monitoring
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(onitoring ICP
:entriculostomy7
)5) :entricular Catheter (onitoring 3evice
Fine bore catheter is inserted into the nonB
dominant hemisphere of the brainCatheter connected to a transducer that monitorsthe ICP and ;ecords dataBscillator scope
)llo2s for ICP relief by allo2ing for CSF release
thus relieving intercranial !.&Intraventricular (ed )dministration access
)ir or contrast administration for :entriculography
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Ventriculostomy with fber optictransducer-tipped device
Complication of
Ventriculostomy:
Infection
Meningitis
Ventricular
Collapse
Occlusion of
catheter device by
brain or blood
materials
Problems with
monitoring system
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(onitoring ICP $continued%
Subarachnoid Scre2 or 8olt7
Scre2 or bolt is a hollo2 scre2 that isinserted through a hole drilled in the skull
and through a hole cut in the dura materin to the subarachnoid space
!ollo2 scre2 avoids complications from brainshifting
3oesnt re?uire ventricular puncture
Infection < clogging scre2 2ith brain mattera4ecting readings
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Subarachnoid screw or bolt
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(onitoring ICP $continued%
-pidural Sensor7
-pidural 3evice is placed through aburr hole drilled in the skull, #ust overthe epidural covering Esespneumatic pressure to signal analarm for pressure abnormalities
-pidural lining is not perforated, thusless invasive < less infection
Cannot relieve e6cess CSF
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(onitoring ICP $continued%
Fiber ptic Sensor
Fiber ptic device can be insertedinto the ventricle, subarachnoid andsubdural space (iniB.ransducerconverts ICP readings into electronicdigital monitoring
"hen inserted in to the ventricle canallo2 for CSF 2ithdra2al
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.rending ICP :alues
ICP "aves7
) "avesBCan last B0minutes 2ith amplitudesbet2een 0B100 mm!g
8 "avesB0 seconds to minutes 2ithamplitudes up to 0mm!g
C "aves * ccur up Gtimes a minute 2ithamplitudes up to mm!g
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&e2 .rends in &euro (onitoring
/ico6 Catheter
) in 1 2hite mattercatheter that measures ICP,.emperature, and endcapillary tissue o6ygen level
@ives real time feed back ofICP management, guidingtherapy and o6ygenation oftissue at risk in thecerebrum
.he temperature probe canbe replaced 2ith amicrodialysis probe
Picture from I&.;-@) 2ebsite7 http7==222integraBiscom=P3Fs=lico6=&S+H0ICPH0CatheterH02H0I(C
H08oltpdf
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/ate (anifestations of Increased ICP
Further deterioration of /C stuporto coma
3ecreasing level of responsiveness accidity may occur
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Decorticate Posturing
Decerebrate Posturing
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/ate (anifestations of Increased ICP cont
)lterations in vital signs
Increase in systolic blood pressure
"idening of pulse pressure
Slo2ing of the heart rate pulse may >uctuate
rapidly from tachycardia to bradycardiaIncrease in temperature
Cushings !riad7 bradycardia, hypertension,< bradypnea
Immediate intervention re?uired to preventherniation of brain stem < occlusion of blood >o2
Cessation of cerebral blood >o2 results in cerebralischemia, infarction, < brain death
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/ate (anifestations of Increased ICPcont
:isual changes pupillary changes re>ectingpressure on optic=oculomotor nerves
Pupils decrease or increase in si9e or become une?ual
/ack of con#ugate eye movement
Papilledema
Pro#ectile vomiting may occur 2ith increasedpressure on the re>e6 center in the medulla
/oss of brain stem re>e6es, including pupillary,corneal, gag, < s2allo2ing re>e6es
/oss of re>e6es is an ominous sign of approachingbrain death
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/ate (anifestations of Increased ICPcont
Classic J6edand dilated
Kblo2n pupilL)bsence ofoculocephalicre>e6 or KdollseyeL
Picture7 http7==imagesgooglecom=imgresMimgurl'http7==222o2lnetriceedu=Npsyc1=Images=3ilatedPupil#pg
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/ate (anifestations of Increased ICPcont
(a#or complication ofIncreased ICP B!ernation
$1% !erniation of the
cingulate gyrus under thefal6 cerebri $% Centraltranstentorial herniation$% Encal herniation of
the temporal lobe intothe tentorial notch $R%Infratentorial herniationof the cerebral tonsils
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/ate (anifestations of Increased ICPcont
3iabetes insipidus is theresult of decreasedsecretion of antidiuretichormone $)3!%
SI)3! is the result of
increased secretion of)3!)ll information other than the /ico6 slide, and blo2n pupil slide is from 8runner < Suddarths .e6tbook of (edicalBSurgical
&ursing, 11th edition http7==thepointeeditionl22com=pt=re=T+A0+A1+T+AG=bookcontent01GTGB11thO-ditionBRhtm#sessionid'[email protected]/VgV+m6@yvpykn;hhvP;:UG5pkpWsU..TA;tPFhy/XBTAG1TRX1A11TGTXA0T1XB1 Information compiled by Stephen Strom, (ichelle !arris, )ngela;eaves, Su9anne Finch, and )manda 5ing
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