1. Management of Raised ICP Jon-Paul Chamoun

2. Case study Little Jimmy 24 year old male presents to ED post footy tackle with severe headstrike associated wth loss of consciousness 1 minute. -GCS 14 at the scene -Sore head -On examination HR 85 reg. BP 130/80 RR 22 36.8 CVS, Abdo, Resp NAD Neuro: PEARL UL + LL Normal Tone Power Reflexes Sensation and Coordination

3. Tea Break! Beep Beep ‘Hi Dr, please review little Jimmy. Drowsy ++’ Crap, I missed the SSSM Neurosurg topics!

4. Little Jimmy.. Now HR 40 BP 180/90 RR 8 36.8 Drowsy+++ Eyes crossed Pupils dilated…

5. PANIC = Neurons not firing

6. RIP Little Jimmy A bad referral leads to…

10. The drainage

11. Physiology Inside the rigid Vault (~ 1500mls) -Brain (80%) -Blood (10%) -CSF (10%)

12. Intracranial Pressure Normal : <15mmHg (adults) Lower in children than adults Transiently increases with sneezing, coughing and valsalva manouvres

14. The overall volume of the cranial vault cannot change therefore an increase in the proportion of one component, or the presence of a pathologic component will result in displacement of structures, an increase in ICP or both. ….Who’s Doctrine is this??

15. The Monroe-Kellie Doctrine

17. Causes  Too much Brain -Tumour, Haematoma, Oedema  Too much CSF -Choroid plexus papilloma, Arachnoid granulation adhesions, Obstructive hydrocephalus  Too much Blood - Obstruction of venous outflow (venous sinus thrombosis, jugular vein compression, neck surgery)

18. Consequences of Raised ICP 1. Cerebral blood flow -CBF = (CAP – JVP) / CVR -CPP = MAP - ICP 2. Brainstem compression 3. Both

19. What was happening to Jimmy? HeadacheVomiting Depressed Consciousness Fixed and dilated pupils A triad of Bradycardia, Hypertension and respiratory depression….Also known as who’s triad?

20. Cushing’s Triad

21. Papilloedema

22. Little Timmy (Jimmy’s Brother) 20 year old male presents to ED post footy tackle with severe headstrike associated wth loss of consciousness 1 minute.

23. The next intern attended SSSM talks… D anger D anger R esponse (GCS) R esponse (GCS) S end for help (!!!!!!!) S end for help (!!!!!!!) A irway A irway B reathing B reathing C irculation C irculation D ont(EverForgetGlucose) D ont(EverForgetGlucose) IWho am I SWhats happened BWhat’s happening AWhat I think RWhat I need

24. Eyes 4: Spontaneous eye opening 3: Eye opening in response to speech 2: Eye opening in response to pain 1: No eye opening Voice 5: Oriented 4: Confused conversation 3: Inappropriate speech 2: Incomprehensible speech 1: None Motor 6: Obeying commands 5: Localising response to pain 4: Withdraws to pain 3: Flexor response to pain 2: Extensor posturing to pain 1: No response to pain Glascow Coma Scale

25. How do we know there’s raised raised ICP?  ICU! Monitoring of ICP is integral to treatment Monitor ICP and BP to determine CPP Many Types of monitors

26. Indications for ICP monitoring 1.History 2.Clinical findings 3.Imaging

27. CT

28. Treatment FIX THE CAUSE!  REMOVE THE BLOOD CLOT  RESECT THE TUMOUR  SHUNT THE CSF  TREAT THE METABOLIC DISORDER

29. Generally.. Apropriate resuscitation (ABC) A – GCS <8, intubate (carefully) B – Give O2 C – Ensure good end organ perfusion....and treat the raised ICP!

30. Specifically..  Sedation  Elevate the head  Hyperventilation  Mannitol  Removal of CSF  Decompressive craniectomy

31. Sedation -Reduce metabolic demand -Reduce venous congestion -Reduce sympathetic response of hypertension and tachycardia

32. Position Elevate head to maximise venous outflow (as long as cerebral perfusion pressure remains appropriate) Minimise stimuli that can induce Valsalva responses (eg endotracheal suctioning)

33. Mannitol Reduces brain volume by drawing free water our of the tissue and into the circulation Quick acting and Effects short lived Problems – Can lower BP and therefore CPP

34. Mechanical Hyperventilation Lowering PaCO2 to 26 to 30 mmHg has been shown to rapidly reduce ICP through vasoconstriction and a decrease in the volume of intracranial blood. Effects short lived. Used as an urgent intervention, not on a chronic basis. May cause critical decrease in local cerebral perfusion (minimise use in TBI or actue stroke)

35. Removal of CSF Ventriculostomy to remove CSF http://www.uptodate.com/contents/image?imageKey=NEURO%2F56391&topicKey=NEURO%2F1659&rank=1%7E150&source=see_link&search=i cp&utdPopup=true

36. Decompressive craniectomy Circumvents Monroe-Kellie doctrine Lowers ICP by 70% Improves brain tissue oxygenation

37. Summary Management requires -Recognition -Monitoring -Therapy aimed at reducing ICP and treating the underlying cause

38. Neurosurgical Pop Quiz ‘Wacky, Wet and Wobbly’ is a good way to remember the symptoms of A. Someone with a weak bladder who’s had too many beers B. An overweight delirious patient coming out of a pool C. Normal Pressure Hydrocephalus

39. Neurosurgical Pop Quiz Which surgeon is known as ‘the father’ of modern neurosurgery?

40. Harvey Cushing

41. Questions?