1. Altered Cerebral Function and Increased intracranial pressure (ICP) Ashley Valentino MSN, BSN, RN updated Spring 2013
From the notes of Charlene Morris MSN, RN
John Nation MSN, RN
&
Marnie Quick MSN, RN, CNRN

2. Head Injury
Head injury – a broad classification that includes any injury or trauma to _____, ______, or _______.
TBI is a serious form of head injury
5.3 million live with disabilities resulting from TBI
MVC, falls most common cause
Other causes?
Males twice likely to sustain TBI than females
Head trauma= high potential for poor outcome**
Deaths from trauma occur at what points?
**Factors that predict poor outcome = ICP levels > than 20 mmHg, presence of intracranial hematoma, abnormal motor responses, GCS on arrival**

3. Glasgow Coma Scale
A score of 13 to 14 indicates mild deficit. A score between 9 and 12 points to moderate deficit, and a score of 8 or less indicates severe coma.

4. GCS on arrival strong predictor of survival!!
Head Injury: TBI
GCS on arrival strong predictor of survival!!
GCS below ____ indicates only 30%-70% chance of survival
Majority of deaths occur immediately after injury
- massive hemorrhage
- shock
** Monitor neurological status; prompt surgical intervention critical in prevention of death**

5. Head Injury: Scalp Lacerations
External head trauma
Associated with profuse bleeding
Major complications:
Bleeding
Infection

6. Head Injury: Skull Fractures
Frequently occur with head trauma
Major complications = intracranial infections, hematoma, brain tissue damage
Characteristics:
linear vs. depressed
simple, comminuted, compound
open vs. closed
Severity of skull fracture depends on?
TX – possible craniotomy if loose bone fragments
craniectomy if large amounts of bone destroyed

7. http://health. rush. edu/HealthInformation/HIE%20Multimedia/2/19084

8. Head Injuries: Manifestations
Depends on location of fracture (Box 57-7)
Symptoms can evolve over course of several hours
- Battle’s sign- what is this?
- Rhinorrhea – patient teaching?
- Otorrhea
If these occur, raise HOB & notify physician immediately!!
** Risk of _________ is high with a CSF leak **
- what will be administered?
- Dextrostix, Tes-tape, halo
- NG tube??

9. Head Trauma: Concussion
Minor diffuse injury
GCS 13-15
change in LOC
may or may not lose total conciousness
Postconcussion syndrome
- 2 wks – 2 months after injury
- What s/s will you see?
- What will we teach?

10. Diffuse Axonal Injury (DAI)
Results after mild, moderate, or severe TBI
Damage to cerebral hemispheres, basal ganglia, thalamus, and brainstem
axon swelling and disconnection
12-24 hours to develop
Symptoms:
- decreased LOC
- increased ICP, global cerebral edema
- what else will you see?
*90% patients with DAI remain in vegetative state*

11. Focal Injury: Laceration
actual tearing of brain tissue
Can occur with depressed or open fractures with penetrating injuries
** Tissue damage severe **
surgical intervention impossible
Medical management – like what?
Intracerebral hemorrhage associated with cerebral laceration – poor prognosis!
- Leads to increased ICP, expansion of hematoma

12. Focal Injury: Contusion
bruising of brain tissue; localized
minor to severe- GCS scale?
most associated with closed head injury
may contain areas of
- hemorrhage, infarction, necrosis, and edema
occurs at fracture site
seizures common complication
Coup- countercoup injury (often noted)
brain moves inside skull
related to high impact injury
multiple contused areas

13. Focal Injury: Contusion
Prognosis depends on what?
May continue to rebleed
appear to “blossom” on CT scan
- * worse neurological outcome **
seizures common complication
anticoagulant use associated with ________,
__________, and ___________.
What should we assess for?

14. Focal Injury: Epidural Hematoma
results from bleeding between the _____ and inner surface of the skull
** Neurological emergency!! **
rapid surgical intervention
what S/S will you see?
associated with linear fracture
crosses major artery in dura
causes tear
can be venous or arterial in origin
Venous tear = develop slowly
arterial tear = rapidly developing, high pressure
- often includes meningeal artery

15. Focal Injury: Subdural Hematoma
occurs from bleeding between the ______ and the
_______ _____ of the ________.
usually results from injury to brain tissue and blood vessels
more common in older adults – why?
can be confused with dementia
usually venous in origin – develops?
sagittal sinus = source of most subdural hematomas
can be acute, subacute, and chronic

16. Focal Injury: Subdural Hematoma
Acute subdural hematoma
24 – 48 hours after trauma
immediate deterioration – what will we see?
treatment?
Subacute subdural hematoma
48 hr – 2 wk after trauma
alteration in mental status as hematoma develops
Chronic subdural hematoma
> 20 days after injury
progressive alteration in LOC
TX = evacuation, membranectomy

17. Focal Injury: Inracerebral Hematoma
occurs from bleeding within brain tissue
usually in frontal and temporal lobes – why?
occurs in 16% of head injuries
the _______ and ______ of hematoma determines patients outcome

18. Diagnostic Tests
______ is best diagnostic tool to evaluate for head trauma
Other studies:
MRI
PET
Transcranial Doppler – assess what?
Cervical Spine Xray

19. Treatments
** Prevent secondary injury = manage elevated ICP; treat cerebral edema **
timely diagnosis, surgery if necessary!
** significant neurological impairment = surgical evacuation! **
Burr holes – used in extreme emergency
followed by craniotomy
drain placed – to prevent what?
If extreme swelling expected = hemicraniectomy – why?

20. Burr Holes

21. Planning: Overall Goals
maintain adequate cerebral oxygenation & perfusion
remain normothermic
achieve pain control, reduce anxiety
free of infection
attain maximal motor, cognitive, and sensory function

22. Nursing Interventions
Health promotion – like what?
** Monitor for changes in neurological status **
maintain cerebral perfusion and oxygenation
hemodynamic monitoring
be aware of coexisting injuries or conditions
Frequent Neuro checks
calm approach, reduce anxiety
maintain temp of 36 to 37 degrees C – cooling blanket?
sedation as necessary – prevent what?
administer antiemetics for nausea/vomiting – why?

23. Nursing Interventions
Provide patient/family support – spiritual care?
surgery consent
provide frequent status updates, open visitation
Home care
prevention of seizures
drug of choice?
assess nutritional status
speech therapy, OT, PT
assistance with financial aid, child care, social work
no driving, no drinking, no use of firearms
assist with role change (spouse to caregiver)

24. Brain Tumors Can occur in brain or spinal cord
rarely metastasize outside CNS
contained by meninges
White males have highest incidence of malignant brain tumors
Primary vs. secondary
Secondary most common type
primary = arising from tissues within the brain
gliomas (glioblastoma, astrocytoma)
secondary = resulting from metastasis

26. Brain Tumors: Manifestations
Depend on _______ and ______ of tumor.
Headaches (common)
worse at night, may awake from sleep
dull, constant; throbbing
Seizures
common in gliomas
Nausea, vomiting – caused by what?
memory problems, personality changes
muscle weakness, sensory loss, aphasia
Hydrocephalus – leads to what?
**brain tumor left untreated = increased ICP, death**

27. Brain Tumors: Diagnostic Studies
Extensive history; comprehensive Neuro exam
New onset of seizures?
MRI, PET -detection of what?
CT = location of lesion
EEG
Why not lumbar puncture??
Angiography – looks at what?
Computer guided stereotacitc biopsy – preliminary

28. Brain Tumors: Treatment
Goals:
identify tumor type, location
remove or decrease tumor mass
prevent/manage ICP
Surgical therapy
surgical removal = preferred treatment
partial vs. complete removal
reduces tumor mass, reducing ICP
Ventricular Shunt – risks?
tx for hydrocephalus; gradually put patient in upright position
catheter placed in lateral ventricle; tunneled through skin
drains CSF – drains into where?

30. Brain Tumors: Treatment
Radiation Therapy
follow-up measure after surgery
stereotactic radiosurgery – radiation precisely directed at a location in brain
radiation seeds- may be implanted into brain
complications??
tx with Decardon, Solu-Medrol - how do these work?
Chemotherapy
nitrosoureas
Gliadel wafer – implanted at time of surgery
Ommaya reservoir
Temodar – 1st oral chemotherapeutic agent

31. Brain Tumors: Nursing Intervention
Goals:
maintain normal ICP
maximize neurological functioning
achieve pain control
patient/family aware of prognosis, long term implications
Provide support – end of life, palliative care?
Protect patient from self harm – how?
Prevent seizures/ seizure precautions
Encourage self care; mobility with supervision
Establish communication system
Assess nutritional status – dietary consult? TF?

32. Cranial Surgery: Types
Craniotomy
removal of bone flap; opening into dura to remove lesion
can be used to drain blood; relieve ICP
may have drain
after surgery, bone flap wired or sutured
Stereotactic Radiosurgery
often computer guided
precise location of specific area
used for biopsy, removal of small brain tumors, drainage of hematomas
* What is the advantage here? *

33. Post- Craniotomy

34. Cranial Surgery: Nursing Interventions
Goals:
return to normal consciousness
pain control, nausea
maximize neuromuscular functioning
rehabilitated to maximum ability
Acute Intervention
pre-operative teaching; provide support
post-operative teaching- what to expect
** Primary nursing goal post-op? **
frequent neuro assessments x first 48 hours
monitor fluid & electrolytes – which one?
control pain and nausea – Phenergan?

35. Cranial Surgery: Nursing Interventions
Acute Intervention Continued
keep HOB degrees – expect when?
assess dressing: drainage, color, odor?
* Notify surgeon immediately for increase in bleeding or if clear drainage is present!!! **
If bone flap removed, do not place patient on operative side!
skin, mouth care
scalp care, assess for infection of incision
antiseptic soap or hospital policy

36. Cranial Surgery: Discharge
Encourage independence, maximize functioning
rehabilitation referral – case management
ST, OT, PT – will they need these at discharge?
Assess nutritional status
Patient/family support

37. Intro to Intracranial Pressure:
Skull is a closed box; 3 essential volume components
brain tissue – 78%
blood – 12%
cerebrospinal fluid (CSF) – 10%
What is Intracranial Pressure (ICP) ?
hydrostatic force measured in brain CSF compartment
a balance among 3 essential components maintains ICP

38. What factors influence ICP?
Changes in:
arterial pressure
venous pressure
intrabdominal or intrathoracic pressure
posture
temperature
blood gases – specifically which one?
* An increase or decrease in ICP depends on the ability of the brain to accommodate to changes *

39. Monro-Kellie doctrine:
Alexander Monro & George Kellie (18th century)
* Only applies to closed skull*
“ The three components must remain relatively constant within the closed skull structure”
“ If the volume of any 3 components increases, volume from another component will decrease; the total intracranial volume will not change”
compensatory adaptations?
What if compensatory adaptations fail?

40. How is ICP measured?
Measured in ventricles, subarachnoid space, subdural space, or brain tissue – using what?
** Normal ICP = 5 – 15 mmHg **
A sustained pressure above the upper limit is considered abnormal

41. ICP Pressure Transducer

42. Cerebral Blood Flow:
Cerebral blood flow (CBF) = amount of blood in ml passing through 100 g of brain tissue in __________
universal CBF = 50ml/min per 100g brain tissue
** Difference in blood flow between white matter and gray matter of the brain **
gray matter faster blood flow (75ml/min)
white matter slower blood flow (25ml/min)
Maintenance CBF critical – what does the brain need?

43. How is CBF Regulated?
Brain regulates own CBF in response to metabolic needs
____________ is the automatic adjustment in size of cerebral blood vessels to maintain constant blood flow
What is the purpose?
**Only effective in a person with MAP of 50mmHG – 150 mmHg **
< 50 mmHg = CBF decreases; cerebral ischemia
What symptoms would you see?
> 150 mmHg = vessels maximally constricted

44. CPP = Flow x Resistance Regulating CBF
___________ is the pressure needed to ensure adequate blood flow to brain
CPP = MAP- ICP
does not consider effect of cerebral vascular resistance
CPP = Flow x Resistance
increase in cerebral vascular resistance= impaired blood flow to brain
Normal CPP 60 – 100 mmHg

45. Transcranial Doppler
Used to measure what?

46. ** Critical to maintain MAP when ICP elevated**
Regulating CBF
AS CPP decreases, autoregulation fails
leads to decrease in CBF
** CPP < than 50 mmHg = ischemia, neuronal death **
CPP < 30 mmHg = not compatible with life
** Critical to maintain MAP when ICP elevated**
Which patient’s may need a higher CPP?

47. What affects CBF? Cardiac, respiratory arrest diabetic coma
systemic hemorrhage
* When autoregulation lost, CBF influenced by BP, hypoxia, catecholamines *

48. C02, 02 hydrogen ions affect vessel tone
What affects CBF?
C02, 02 hydrogen ions affect vessel tone
PaCO2 vasoactive agent
- Increase in PaCO2= dilation
- Decrease in PaCO2 = constriction
decrease in 02 tension = accumulation of lactic acid, increasing acidic environment
increased dilation occurs; autoregulation may be lost

49. Intracranial Pressure-volume curve
Changes in Pressure
_________ is the expandability of the brain
Compliance = Volume/Resistance
Low compliance – small change in volume causes increase in pressure
Intracranial Pressure-volume curve
Stage 1 = total compensation
Stage 2 = at risk for increase in ICP
Stage 3 = great increase in ICP
- Stage 4 = ICP rises to lethal levels

50. Pressure -Volume Curve*

51. Pressure Changes Loss of autoregulation = rise in BP
Cushing’s Triad – what will you see?
neurological emergency!!
Stage 4 = herniation
Intense pressure placed on ________.
compression of _______ and ________
if herniation continues – what will occur?

52. Mechanisms of Increased ICP:
Mass lesion – like what?
Cerebral edema – from what?
Metabolic insult
Result in impaired autoregulation, systemic hypertension – leading to cerebral edema
Increase in edema – distorts brain tissue – increase in??
** To preserve tissue = maintain CBF!! **
** Any patient who becomes acutely unconscious, suspect what??

53. Cerebral Edema Increase in tissue volume Leads to? Three types:
vasogenic
cytotoxic
interstital

54. Vasogenic Cerebral Edema
Most common type
caused by changes in endothelial lining of cerebral capillaries
leakage into extracellular space
occurs mainly in white matter
Influenced by BP, site of brain injury, and extent of blood-brain barrier defect
Can lead to coma
headache may be first sign
sharp assessment skills necessary; progresses quickly !

55. Cytotoxic Cerebral Edema
disruption in integrity of cell membranes
result of trauma; cerebral hypoxia or anoxia
occurs most often in gray matter
result of protein shift
blood-brain barrier remains intact
swelling and loss of cellular function

56. Interstitial Cerebral Edema
result of rupture of CSF brain barrier
hydrocephalus – what is this?
tx with ventricular shunt
can be caused by systemic water excess
hyponatremia, water intoxication

57. Increased ICP: Manifestations
Change in LOC
result of impaired CBF
deprives cells of 02
interruptions of impulses from RAS
leads to abnormal state of complete or partial awareness – called what?
recorded by a EEG
Changes in LOC range from flat affect or change in orientation to coma
what will you see with coma?

59. Increased ICP: Manifestations
Changes in VS – caused by what?
Cushing’s triad – medical emergency!!
What will you see?
What about temperature?
Occular Signs
dilation of pupil – which one? Indicates what?
sluggish, no response to light
ptosis of eyelid
blurred vision, diplopia
papilledema – what is this?

62. Increased ICP: Manifestations
Decrease in Motor Function
contralateral hemiparesis- meaning what?
hemiplegia
decorticate vs. decerebrate posturing
what does this indicate?
Headache
continuous, worse in the morning
What can accentuate the pain?
Vomiting – will they complain of nausea?

63. Decorticate posturing- abnormal flexion Decerebrate posturing- abnormal extension

65. Diagnostic Studies Identify presence and cause of increased ICP MRI CT
EEG
Angiography
PET
why not LP?

66. Monitoring of ICP:
Should be monitored in patients with GCS < or equal to 8; and abnormal CT or MRI
monitored in ICU
Ventriculostomy
“gold standard”
catheter inserted into lateral ventricle
coupled to an external transducer
directly measures pressure in ventricle
facilitates removal of CSF
intraventricular drug administration

67. Monitoring of ICP:
Fiberoptic catheter
alternative technology
sensor transducer within catheter tip
placed within ventricle of brain
direct measurement of brain pressure

68. Monitoring of ICP: Subarachnoid bolt or screw placed through skull
between arachnoid membrane and cerebral cortex
does not allow CSF drainage
ideal in patient’s with mild to moderate head injury
can easily be converted to ventriculostomy if needed

69. ICP Monitoring: Complications
Infection – what increases risk?
> 5 days of monitoring
use of ventriculostomy
presence of CSF leak
concurrent systemic infection
prophylactic antibiotics may be given!
Monitor CSF drainage for what?

70. Normal ICP Waveforms: P1 – percussion wave P2 – rebound or tidal wave
represents arterial pulsations
highest of the three waveforms
P2 – rebound or tidal wave
reflects intracranial compliance
when P2 > P1 = compromised compliance
P3 – dicrotic wave
represents venous pulsations
lowest waveform
follows dicrotic notch

72.  Intracranial pressure monitoring can be used to continuously measure ICP. The ICP tracing shows normal, elevated, and plateau waves. At high ICP the P2 peak is higher than the P1 peak, and the peaks become less distinct and plateau.

73. ICP Waveform:
CSF drain must be closed for at least _______ to ensure an accurate reading.
Notify physician promptly for any abnormal change in waveform!!
What can cause an inaccurate ICP reading?

74. Draining CSF: May control ICP
MD order: specific level to initiate drainage
intermittent vs. continuous drainage
how long with intermittent?
opened with stopcock valve
normal CSF 20 – 30 ml/hr
careful monitoring of volume essential!!
prevent removal of too much CSF – how?

75. Draining CSF: Complications?
CSF removal based on institution policy or physician preference
Complications:
ventricular collapse
infection
herniation
subdural hematoma

76. Cerebral Oxygenation Monitoring (Pbt02):
LICOX – measures what?
placed in white matter of brain
continuous monitoring of Pbt02 – normal range?
low Pbt02 indicative of what?
ability to measure _____________.
Jugular Venous Bulb Catheter
measurement of Sjv02
measures cerebral oxygen supply and demand
normal range 55% to 75%
< 50% demonstrates what?
Can these measure ICP??

77. Collaborative Care: Identify and TX underlying cause – obtain what?
Normal causes?
Support brain function
Ensure adequate oxygenation
ET tube, tracheostomy
ABG’s – goal for Pa02? Goal for PaC02?
Surgical removal of mass or lesion
hemicraniectomy
Diuretics, Corticosteroids

78. Collaborative Care: Drug Therapy
Mannitol – how does it work? Contraindicated when?
monitor fluid and electrolyte status
Hypertonic Saline
raises osmolality; decreases cerebral water content
used concurrently with Mannitol
requires frequent BP monitoring, Na+ levels – why?
Corticosteroids – like what? Side effects?
treat vasogenic edema
not recommended in head injury patients
improve CBF, restore autoregulation

79. Collaborative Therapy:
What else may increase ICP??
maintain fever at 36 – 37 degrees C
Keep patient in quiet, calm environment
Barbituates
total burst suppression?
Nutritional Therapy
early feeding improves outcomes
TF may be initiated
0.9% NS preferred IV solution

80. Nursing Management: ICP
Glasgow Coma Scale (GCS)
assesses LOC
opening of eyes – spontaneous, to pain?
best verbal response – appropriate, confused?
the best motor response – withdraw? Respond to verbal command?
What is the highest GCS for a fully alert person?
When is a coma indicated?

81. Nursing Management: Neuro Assessment
compare pupils – ipsilateral or bilaterally dilated?
pupillary reaction – sluggish, fixed?
eye movements – doll’s eye?
palmar drift
Why not use hand squeezing?
assess BP, pulse, respiratory rate, temp – looking for what?

85. ICP: Nursing Intervention
Acute Intervention
** Maintenance of airway **
keep patient lying on one side
suction as needed; < than 10 seconds in duration
suction limited to 2 passes
When is intubation required?
Prevent hypoxia
Elevate HOB > than 30 degrees
Prevent Abdominal distention
NG tube – when contraindicated?

86. ICP: Nursing Intervention
Manage pain, anxiety, fear
Administer sedatives, analgesics, paralytics
alter neurologic state; temporary “drug suspension”
Propofol (Diprovan)
Precedex (continuous IV sedation)
Monitor ABG’s
Monitor IV fluids/electrolytes – which ones?
SIADH
Protect patient from harm (seizures, falls, etc. )