1. Increase Intracranial Pressure

3. Brain Brain tissue (1,400g) Blood (75mL) CSF (75mL)
Normal ICP 10 to 20 mmHg

4. Monro-Kellie Hypothesis
Limited space for expansion in the skull, an increase in anyone of the components causes a change in the volume of the others.

5. Pathophysiology

6. Increase ICP is a syndrome that affects many patients with acute neurologic conditions. This is because pathologic conditions alter the relationship between intracranial volume and pressure.

7. Elevated ICP most commonly associated with head injury
Secondary Effects
Brain tumors
Subarachnoid hemorrhage
Toxic and viral encephalities

9. Diagnostic Findings

10. Cerebral Angiography
Computed Tomography (CT) Scanning
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET)
Transcranial Doppler

11. Cerebral Angiography The first image shows normal brain blood flow
The second image shows presence of cerebral aneurysm that can cause decease cerebral blood flow may lead to increase ICP

12. Computed Tomography Scanning
The first image shows a normal view of the brain
The second image shows brain with tumor and edema that may lead to increase ICP

13. Magnetic Resonance Imaging
The first image shows normal MRI result
The second image shows with brain tumor that causes increase ICP

14. Positron Emission Tomography
The first image shows normal PET result
The second image shows with brain tumor that may lead to increase ICP

15. Transcranial Doppler The top shows a TCD of a normal artery
Bottom shows a severely stenosed internal carotid artery causes decrease cerebral blood flow may lead to increase ICP

16. ICP Precautions Elevate head of bed 30 degrees.
Seizure prophylaxis: Phenytoin will reduce seizures in the first week after injury but does not change the overall outcome.
Steroids are ineffective in controlling ICP in the trauma setting.

17. Manipulation of ICP Blood Decrease cerebral metabolic demand
sedation, analgesia, barbiturates
avoid hyperthermia
avoid seizures
Hyperventilation
decreases blood flow to brain
only acutely for impending herniation
Mannitol

18. Manipulation of ICP Brain Mannitol Hypertonic saline
dehydrate the brain, not the patient!
monitor osmolality
Hypertonic saline
Decompressive craniectomy

19. ICP Monitoring
ICU patients who have sustained head trauma, brain hemorrhage, brain surgery, or conditions in which the brain may swell might require intracranial pressure monitoring.
The purpose of ICP monitoring is to continuously measure the pressure surrounding the brain.

20. Why Monitor? Detect “events” Manage intracranial pressure
Manage cerebral perfusion pressure

21. How? Ventriculostomy Intraparenchymal fiberoptic catheter
Subarachnoid monitor
Useful adjuncts:
Arterial line
Central venous line
Foley catheter

22. Manipulation of ICP CSF External drainage
therapeutic as well as diagnostic
technical issues
infectious issues

23. What to do with the information...
Goal: adequate oxygen delivery to maintain the metabolic needs of the brain.
Intracranial pressure <20
Cerebral perfusion pressure >50-70 mm Hg CPP=MAP-ICP

24. Indications for ICP monitoring
Glasgow coma scale <8
Clinical or radiographic evidence of increased ICP
Post-surgical removal of intracranial hematoma
Less severe brain injury in the setting which requires deep sedation or anesthesia

25. Management of Raised ICP
Measure ICP
Maintain CPP>70 mm Hg
Management of Raised ICP
Raised ICP>25mm Hg
First Line Rx
Ventricular Drain
Raised ICP>25mm Hg CT
Normal Vent/Oxygenation
Mannitol
Sedation

26. Management of Raised ICP
Maintain CPP>70 mm Hg
Management of Raised ICP
Raised ICP>25mm Hg
Furosemide
Chemical Paralysis
CSF Removal
Vasopressor
Second Line Rx
Raised ICP>25mm Hg
Barbiturates
Hyperventilation
Monitor SjO2

27. The Patient with Increased Intracranial Pressure
Nursing Process
The Patient with Increased Intracranial Pressure

28. Assessment

29. History
Present Illness
Obtain Subjective Data
Neurologic examination
Mental Status
LOC
Cranial Nerve Function
Cerebral Function (balance and coordination)
Reflexes
Motor and Sensory Function
Abnormal Respiratory Pattern

30. Nursing Diagnosis

31. Ineffective airway clearance related to diminished protective reflexes
Ineffective breathing patterns related to neurologic dysfunction
Ineffective cerebral tissue perfusion related to the effects of increased ICP
Deficient fluid volume related to fluid restriction
Risk for infection related to ICP monitoring system

32. Planning and Goals

33. Maintenance of patent airway
Normalization of respiration
Adequate cerebral tissue perfusion through reduction in ICP
Restoration of fluid balance
Absence of infection
Absence of complication

34. Nursing Intervention

35. Maintaining patent airway and adequate ventilation
Monitor vital signs and neurochecks
Maintain fluid balance
Position client with head of the bed elevated 30 to 45 degrees and neck in neutral position
Maintain a quiet environment
Avoid use of restraints
Prevent straining at stool
Prevent excessive cough and vomiting
Prevent complication of immobility
Preventing infection
Administer medication as ordered

36. Evaluation

37. Maintained patent airway
Attains optimal breathing pattern
Attains desired fluid balance
Infection prevented
Complications prevented