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Intracranial Pressure Management: The Delicate Balance

Peter S. Cenek, MSN, APN-CNS, CNRN

Objectives

• Become more familiar with Neuro Anatomy as it relates to intracranial pressure (ICP)

• Understand the factors that increase ICP and how to treat them

• Learn the management of cerebral perfusion pressure

• Increase comfort level with caring for a patient with a ventriculostomy

• Be able to relate the Nursing and medical management of a patient with elevated ICP

Little Bit of A & P

Skull

8 Cranial bones

14 Facial bones

Top and sides of inside skull = SMOOTH

Bottom inside = UNEVEN

Foramen Magnum

Largest Hole

Brain stem into spinal cord

Scalp, Cranium, & Meninges

• Dermal layer

• Periosteum

• Bone

• Meninges

– Dura Mater

– Arachnoid

– Pia Mater

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Intracranial Problems

Consciousness

Impaired Cerebral Blood Flow (CBF)

Affects Reticular Activating System (RAS)

Change in LOC can be sudden or subtle

Deep unconsciousness

Loss of Protective Reflexes

• Normal spontaneous movement, no response to pain

• Swallow, cough, gag

• Corneal/pupillary reflexes

• Unable to respond to environment

• Lack of awareness of body position

• Provide hygiene

• Incontinence

Skull

• SKULL IS A BOX - contains blood, CSF, and brain tissue.

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Intracranial Pressure (ICP)

• Normal = 0-15 mmHg

• 3 components:

– 10% CSF

– 12% blood

– 78% brain tissue

• Monro-Kellie hypothesis

– Relative constant volume of the 3

– If volume of one then another must

– Body adapts to maintain normal ICP

Factors Affecting ICP

• Arterial pressure

• Venous pressure

• Intraabdominal & intrathoracic pressure

• Coughing, sneezing

• Posture, body position

• Temperature

• Blood gases ( pCO2 & pO2)

• Clustering activities

Factors Affecting ICP

• PEEP

• Vasodilating drugs

• Isometric muscle contractions

• Valsalva’s maneuver

• Emotional upset

• Noxious stimuli

• Activities that increase cerebral metabolism

Cerebral Blood Flow

• Autoregulation

• Cerebral Perfusion Pressure (CPP) – pressure needed to ensure blood flow to brain (CPP = MAP - ICP)

• CPP > 70

• Elastance

• Compliance

ICP Clinical manifestations: Change LOC, H/A, vomiting, motor function (refer to GCS),

pupillary responsiveness

Loss of autoregulation

Cushing Triad

– Systolic HTN ( Pulse pressure)

– Bradycardia

– Irregular respiratory rate/pattern

ICP

• Cerebral edema contributes to ICP

– Mass lesions

– Head injuries

– Brain surgery

– Cerebral infections

– Vascular insult

– Toxic/metabolic encephalopathy

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Head Injury Head Injury

• Traumatic Brain Injury (TBI)

• Closed head injury (CHI)

• Coup-contrecoup injury

• Penetrating injury

Head Trauma

Predictors of poor outcome:

• Intracranial hematoma

• Age

• Abnormal motor responses

• Impaired/absent eye movements or pupillary reflexes

• Early hypotension

• Early hypoxemia or hypercapnia

• ICP > 20 Sustained

Skull Fractures

Linear

Depressed

Simple

Comminuted

Compound

Basilar Skull Fracture

Base of the skull

Usually temporal & frontal bones

Bones fragile & dura delicate

S & S:

– Infection

– CSF leak (Halo sign)

– Compression of cranial nerves

– Trapping of arachnoid and dura between fracture edges

Basilar Skull Fracture • Rhinorrhea

• Post-nasal drip

• Raccoon’s eyes

• Otorrhea

• Hemotympanum

• Hearing loss

• Facial nerve palsy

(Bell’s palsy)

• Battle’s sign

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Contusion

• Size & severity depends on injury

• Develops areas of hemorrhage, infarction, necrosis, and edema

• On cortical surface

• Seizures common complication

Diffuse Axonal Injury (DAI)

• Forces of injury shear axons

• Trauma changes function of axon

– Axon swelling & disconnection

• S & S:

– LOC

– ICP

– Global cerebral edema

– Decerebration, decortication

• Epidural hematoma

• Subdural hematoma

• Intracerebral hemorrhage

TBI: Nursing Management

• Health promotion (Helmets & seatbelts)

• Maintain cerebral perfusion

• Monitor & reduce ICP

• Neuro assessment hourly

• Treat hyperthermia

• Check for CSF leak

• Seizure monitoring

• Family education

Herniation

• Displacement of brain tissue can become an irreversible patho process

• Ischemia & edema

• Compress brain stem & CN’s can be fatal

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Measurement of ICP

• GCS < 8 AND abnormal CT

• Methods: – Ventriculostomy – “gold standard”

– Bolt – Bolt with CSF drain

– Fiberoptic catheter – intraparenchymal

• Nursing care:

– Assess for infection – Monitor waveform

closely

EVD

• External Ventricular Device/Drain

• Ventriculostomy

• Nursing management:

– Drain CSF hourly

– Note color and amount

– Level at EAC

– Clamp if changing level HOB

– Keep site covered with dressing

ICP Waves

ICP: Collaborative Care

• Elevate the HOB (30-45 degrees)

• Hyperventilation – brief periods lower pCO2

• Nutrition – early feeding improves outcomes

• ICP monitoring

• Moderate dehydration – controversial

ICP: Pharm Management

• Osmotic diuretics (Mannitol) & Loop (Lasix)

• Corticosteroids (Decadron) • H2-Receptor antagonist (Pepcid, Zantac)

• Barbiturates – reduce cerebral metabolism (Pentobarbital)

• Anticonvulsants (Keppra, Dilantin, Depakote)

• Sedation (Diprivan, Versed) • Paralytics (Zemuron)

• Pain control (Morphine and Fentanyl)

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Sedation and the Neuro Patient: Do

they mix?

• Sedatives include:

Versed, Ativan, Valium, Diprivan

Narcotics too

• When NOT to Sedate:

Close monitoring for Neuro changes

• When to Sedate:

Patient may harm self

Pain

Elevated ICP (sustained)

ICP: Nursing Management • Neuro assessment

GCS – standardized

Pupillary check

CN evaluation

Motor function

• Respiratory – maintain airway, monitor ABGs

• Elevate HOB

• NG tube to decompress

• Control pain (sedatives, paralytics, and analgesics combo)

GCS Exam Progression

1. Voice (increase volume with subsequent attempts)

2. Shake patient shoulder to attempt to awaken

3. Painful stimuli (ONLY central stimulation acceptable)

Glasgow Coma Scale (GCS)

BEST Eye opening response

4 = Spontaneous

3 = To name/command

2 = To pain

1 = None

GCS

BEST Motor Response

6 = Commands

5 = Spontaneous/Localize

4 = Flexion/withdraws

3 = Decorticate posturing

2 = Decerebrate posturing

1 = None

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GCS

BEST Verbal Response

5 = Oriented, appropriate

4 = Confused

3 = Inappropriate

2 = Incomprehensible speech

1 = None

GCS Range = 3-15

ICP: Nursing Management

• Vital signs – Remember Cushing triad!

• Fluid & electrolyte balance

• Monitor ICP values and waveforms

• Proper body position (HOB 30-45)

• Protect from injury Restraints

Prevent seizures

Balance of sensory deprivation and overload

• Psychological support for patient & family

Patience!

• Takes time

• Brain healing

• ICP Management is so important, although very complex

• Continuous trials/combinations of treatment modalities

• Multidisciplinary – consultation with expert clinicians