I C P

Increased Intracranial Pressure By: Anthony P. Toledo, MD, Rn Chairman, MS2 INTRACRANIAL PRESSURE •Pressure exerted by the volume of the intracranial contents within the cranial vault •Measured in the lateral ventricles •Has a normal pressure of 10-20 mmHg RIGID CRANIAL VAULT Contains

- Brain Tissue (1,400 g) - Blood (75 ml) - CSF (75 ml)

[The 3 components are usually in state of equilibrium and produce the ICP] MONRO-KELLIE HYPOTHESIS: “Because of the limited space for expansion within the skull, an increase in any one of the components causes a change in the volume of the others” Pathophysiology Head Injury (most common cause)

Increase ICP Decrease cerebral perfusion Edema Shifting of brain tissue through openings in the rigid dura Herniation Death (frequently fatal event)

Cerebral Edema (swelling) •Abnormal accumulation of water or fluid in the intracellular space, extracellular space, or both •Can occur in gray, white or interstitial matter AUTOREGULATION Brain’s ability to change the diameter of its blood vessels automatically to maintain a constant cerebral blood flow during alterations in systemic BP Cerebral Response to Increased ICP CUSHING’S RESPONSE / CUSHING’S REFLEX •

Brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

•

Is seen when cerebral blood flow decreases significantly

CUSHING’S TRIAD •

Three classical signs: Bradycardia, Hypertension, Bradypnea

•

Seen with pressure on the medulla as a result of brain stem herniation •

Herniation – shifting of brain tissue from an area of high pressure to an area of lower pressure

Clinical Manifestations of increased ICP •

Changes in LOC

•

Abnormal respiratory and vasomotor response

•

Decortication – An abnormal posture associated with brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities

•

Decerebration- An abnormal body posture associated with severe brain injury, characterized by extreme extension of the upper and lower extremities

Assessment and Diagnostic Findings •

Cerebral Angiography

•

CT scan

•

MRI

•

PET

•

Transcranial Doppler – provides information about cerebral flow

Complications •

Brain stem herniation

•

Diabetes Insipidus

•

Syndrome of Inappropriate Anti Diuretic Hormone (SIADH)

Management 1. Monitoring ICP •

To identify increased pressure before cerebral damage occurs

•

To quantify the degree of elevation

•

To initiate appropriate treatment

•

To provide access to CSF for sampling and drainage

•

To evaluate effectiveness of treatment

VENTRICULOSTOMY – A catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid SUBARACHNOID BOLT – (screw) Device placed into the subarachnoid space to measure intracranial pressure EPIDURAL MONITOR – A sensor placed between the skull and dura to monitor intracranial pressure FIBEROPTIC MONITOR – A system that uses light refraction to determine intracranial pressure 2. Decrease cerebral edema •

Osmotic Diuretic may be given to dehydrate the cerebral tissue and reduce cerebral edema

•

Corticosteroid helps to reduce the edema surrounding brain tumors when the brain tumor is the cause of increase ICP

•

Fluid restriction

•

Maintain the head of the bed elevated

3. Reducing CSF and Intracranial Blood volume •

CSF drainage – caution should be used because excessive drainage may result in collapse of ventricles

•

Hyperventilation

4. Maintaining cerebral perfusion •

Cardiac output may be manipulated to provide adequate perfusion to the brain

5. Controlling Fever •

Fever increases cerebral metabolism and the rate at which cerebral edema forms

6. Maintaining Oxygenation •

To ensure that systemic oxygenation remains optimal

7. Reducing metabolic demands •

Administer Barbiturates

INCREASED ICP – increase ICP is due to increase in 1 of the Intra Cranial components. Predisposing factors: 1.) Head injury 2.) Tumor 3.) Localized abscess 4.) Hemorrhage (stroke) 5.) Cerebral edema 6.) Hydrocephalus 7.) Inflammatory conditions - Meningitis, encephalitis B. S&Sx change in VS = always late symptoms Earliest Sx: a.) Change or decrease LOC – Restlessness to confusion Wide pulse pressure: Increased ICP - Disorientation to lethargy Narrow pp: Cardiac disorder, shock - Stupor to coma Late sign – change in V/S 1. BP increase (systolic increase, diastole- same) 2. Widening pulse pressure Normal adult BP 120/80 120 – 80 = 40 (normal pulse pressure) Increase ICP = BP 140/80 = 140 – 80= 60 PP (wide) 3. RR is decreased (Cheyne-Stokes = bet period of apnea or hyperpnea with periods of apnea) 4. Temp increase Increased ICP: Increase BP Shock – decrease BP – Decrease HR Increase HR CUSHINGS EFFECT Decrease RR Increase RR Increase Temp Decrease temp b.) Headache Projectile vomiting Papilledema (edema of optic disk – outer surface of retina) Decorticate (abnormal flexion) = Damage to cortico spinal tract / Decerebrate (abnormal extension) = Damage to upper brain stem-pons/ c.) Uncal herniation – unilateral dilation of pupil. (Bilateral dilation of pupil – tentorial herniation.) d.) Possible seizure. Nursing priority: 1.) Maintain patent a/w & adequate ventilation

a. Prevention of hypoxia – (decrease tissue oxygenation) & hypercarbia (increase in CO2 retention). Hypoxia – cerebral edema - increase ICP Hypoxia – inadequate tissue oxygenation Late symptoms of hypoxia – B – bradycardia E – extreme restlessness D – dyspnea C – cyanosis Early symptoms – R – restlessness A – agitation T – tachycardia Increase CO2 retention/ hypercarbia – cerebral vasodilatation = increase ICP Most powerful respiratory stimulant --increase in CO2 Hyperventilate --decrease CO2 – excrete CO2 Respiratory Distress Syndrome (RDS) – decrease Oxygen Suctioning – 10-15 seconds, max 15 seconds. Suction upon removal of suction cap. Ambu bag – pump upon inspiration d. Assist in mechanical ventilation 1. Maintain patent a/w 2. Monitor VS & I&O 3. Elevate head of bed 30 – 45 degrees angle neck in neutral position unless contra indicated to promote venous drainage 4. Limit fluid intake 1,200 – 1,500 ml/day (FORCE FLUID means:Increase fluid intake/day – 2,000 – 3,000 ml/day)- not for inc ICP. 5. Prevent complications of immobility 6. Prevent increase ICP by: a. Maintain quiet & comfortable environment b. Avoid use of restraints – lead to fractures c. Siderails up d. Instruct patient to avoid the ff: -Valsalva maneuver or bearing down, avoid straining of stool (give laxatives/ stool softener Dulcolax/ Duphalac) - Excessive cough – antitussive Dextrometorpham -Excessive vomiting – anti emetic (Plasil – Phil only)/ Phenergan - Lifting of heavy objects - Bending & stooping e. Avoid clustering of nursing activities 7. Administer meds as ordered: 1.) Osmotic diuretic – Mannitol./Osmitrol promotes cerebral diuresis by decompressing brain tissue Nursing considerations: Mannitol 1. Monitor BP – SE of hypotension 2. Monitor I&O every hr. report if < 30cc out put 3. Administer via side drip 4. Regulate fast drip – to prevent formation of crystals or precipitate 2.) Loop diuretic - Lasix (Furosemide) Nursing Mgt: Lasix Same as Mannitol except - Lasix is given via IV push (expect urine after 10-15mins) should be in the morning. If given at 7am. Pt will urinate at 7:15 Immediate effect of Lasix within 15 minutes. Max effect – 6 hrs due (7am – 1pm) S/E of Lasix

1. Hypokalemia (normal K-3.5 – 5.5 meg/L) S&Sx 1. Weakness & fatigue 2. Constipation 3. (+) “U” wave in ECG tracing Nursing Mgt: 1.) Administer K supplements – ex Kalium Durule, K chloride Potassium Rich food: ABC’s of K Vegetables Fruits A - asparagus A – apple B – broccoli (highest) B – banana – green C – carrots C – cantalope/ melon O – orange (highest) –for digitalis toxicity also. Vit A – squash, carrots yellow vegetables & fruits, spinach, chesa Iron – raisins, Food appropriate for toddler – spaghetti! Not milk – increase bronchial secretions Don’t give grapes – may choke S/E of Lasix: 2. Hypocalcemia (Normal level Ca = 8.5 – 11mg/100ml) or Tetany: S&Sx weakness Paresthesia (+) Trousseau sign – pathognomonic – or carpopedal spasm. Put bp cuff on arm=hand spasm. (+) Chevostek’s sign Arrhythmia Laryngospasm Administer – Ca gluconate – IV slowly Ca gluconate toxicity: Sx – seizure – administer Mg SO4 Mg SO4 toxcicity– administer Ca gluconate B – BP decrease U – urine output decrease R – RR decrease P – patellar reflexes absent

3. Hyponatremia – Normal Na level = 135 – 145 meg/L S/Sx –

Hypotension Signs of Dehydration: dry skin, poor skin turgor, gen body

malaise. Early signs – Adult: thirst and agitation / Child: tachycardia Mgt: force fluid Administer isotonic fluid sol

4.

Hyperglycemia – increase blood sugar level P – polyuria P – polyphagia P – polydipsia

Nsg Mgt: a. Monitor FBS (N=80 – 120 mg/dl) 5. Hyperuricemia – increase serum uric acid. Tophi- urate crystals in joint. Gouty

arthritis

kidney stones- renal colic (pain) Cool moist skin Sx joint pain & swelling usually at great toe.

Nsg Mgt of Gouty Arthritis a.) Cheese (not sardines, anchovies, organ meat) (Not good if pt taking MAO) b.) Force fluid c.) Administer meds – Allopurinol/ Zyloprim – inhibits synthesis of uric acid – drug of choice for gout Colchicine – excretes uric acid. Acute gout drug of choice. Kidney stones – renal colic (pain). Cool moist skin Mgt: 1.) Force fluid 2.) Meds – narcotic analgesic Morphine SO4 SE of Morphine SO4 toxicity Respiratory depression (check RR 1st) Antidote for morphine SO4 toxicity –Narcan (NALOXONE) Naloxone toxicity – tremors Increase ICP meds: 3.) Corticosteroids - Dexamethsone – decrease cerebral edema (Decadrone) 4.) Mild analgesic – codeine SO4. For headache. 5.) Anti convulsants – Dilantin (Phenytoin) Question: Increase ICP what is the immediate nsg action? a. Administer Mannitol as ordered b. Elevate head 30 – 45 degrees c. Restrict fluid d. Avoid use of restraints Nsg Priority – ABC & safety

SUMMARY

INCREASED INTRACRANIAL PRESSURE DEFINITION It s the pressure exerted in the cranium by its contents: the brain, blood and cerebrospinal fluid (CSF). ETIOLOGY Increased ICP is most often associated with a rapidly expanding lesion (e.g. bleeding), an obstruction to the outflow of CSF (e.g. tumor), or increased CSF formation (e.g. cerebral edema). RISK FACTORS Clients at the highest risk of developing increased ICP are those who have expanding masses in the brain. Common clients are those who have had an injury to the

head, surgery on the brain, hydrocephalus,, brain tumors and bleeding (e.g., subarachnoid bleeding). ASSESSMENT IN INCREASED ICP a. Restlessness- the initial sign of increased ICP b. Headache, nausea, vomiting and diplopia c. Decrease in level of consciousness d. Vital sign changes- Cushing’s triad (increased systolic pressure, widened pulse pressure and irregular respiration) e. Pupillary changes- anisucoria, pinpoint pupils and fixed dilated pupilis f. Papilledema or Choked disc g. Lateralizing sign- contralateral loss of motor function due to decussation of motor fibers at the level of medulla oblongata.

DIAGNOSTIC ASSESSMENT a. CT Scan and MRI b. Lumbar puncture- usually not performed because of the risk of herniation of the brain stem when the pressure of CSF in the cord is lower than in the cranium. c. Continuous ICP monitoring- commonly used and the equipment monitors the level of ICP and sometimes can drain extra CSF to lower pressure. SURGICAL MANAGEMENT a. Surgical placement of a shunt to allow drainage if CSF is blocked b. Decompressive surgery- done by removing some brain tissue (e.g., part of the temporal lobe) to give remaining structures room to expand.

COLLABORATIVE MANAGEMENT a. Semi-fowler’s, lateral position b. Adequate oxygenation c. Avoid factors that increase ICP- nausea and vomiting, sneezing/coughing, valsalva maneuver, over suctioning, restraints, rectal examination, enema, flexion of waist, hip and neck. d. Control of hypertension e. Restrict fluid intake PHARMACOLOGIC MANAGEMENT a. Osmotic diuretics- most common is mannitol. Side effects of large dose include production of hyperosmolar state, decreased effectiveness with repeated use and aggravation of edema in some clients. b. Loop diuretics- nonosmotic diuretic like furosemide (Lasix). For older clients at risk for congestive heart failure, furosemide may improve the cardiovascular status. c. Steroids- dexamethasone (Decadron). Antacids or H2 blockers may also be prescribed to control gastrointestinal irritation and hemorrhage. d. Antihypersentives- caution is used to avoid cerebral vasodilation. e. Anticonvulsant- Phenytoin (Dilantin) and Phenobarbital are the usual agents. To prevent seizures. f. Barbiturate Therapy for uncontrolled ICP- Pentobarbital is the drug of choice. The use of this treatment requires sophisticated monitoring capacity and trained personnel, but its use has shown increased survival.