Acute Intracranial Problems

Intracranial Pressure

Primary injury occurs at the initial time of any injury

Secondary injury is the resulting hypoxia, ischemia, hypotension, edema, or increased
ICP that follows the primary injury
o May occur hours to days after the initial injury

Regulation and Maintenance of Intracranial Pressure

Normal Intracranial Pressure

o Intracranial pressure (ICP)- the hydrostatic force measured in the brain CSF
compartment
o Balance among three compartments: brain tissue, blood, CSF
o Factors that influence ICP under normal circumstances:
Arterial pressure
Venous pressure
Intraabdominal and intrathoracic pressure
Posture
Temperature
Blood gases
o Monroe-Kelli doctrine- the three components must remain at a constant volume
within the skull.
If any volume of one of the three components increases, another
component is displaced so that total intracranial volume remains
unchanged.
o Normal ICP= 5 to 15 mm HG
Pressure greater than 20mm Hg= abnormal
Normal Compensatory Adaptations
o 3 way to maintain normal ICP
Changes in CSF volume
Collapse of cerebral veins and dural sinuses, regional cerebral
vasoconstriction or dilation, and changes in venous outflow
Distention of the dura (compression of brain tissue)
Cerebral Blood Flow
o Cerebral blood flow- the amount of blood passing through 100 g of brain tissue in
1 minute.
o Global CBF= 50 mL/min/100 g of brain tissue
o Brain uses 20% of bodys oxygen, 25% of its glucose
Autoregulation of Cerebral Blood Flow

o Autoregulation- the automatic adjustment in the diameter of the cerebral blood

vessels by the brain to maintain a constant blood flow during changes in arterial
blood pressure (BP)
o Lower limit= 70 mm Hg, upper limit= 150 mm Hg
Belowcerebral ischemia, syncope, blurred vision
o Cerebral perfusion pressure (CPP)- the pressure needed to ensure blood flow to
the brain
CPP= MAP-ICP
Normal CPP= 60 to 100 mm Hg
As CPP decreases, autoregulation fails and CBF decreases
Less than 50 mm Hg= ischemia and neuronal death
Less than 30 mm Hg = ischemia, incompatible with life
CPP may not reflect perfusion pressure in all parts of the brain
Pressure Changes
o Compliance- the expandability of the brain
Low compliance: small changes in volume causes greater increases in
pressure
o With loss of autoregulation, body maintains homeostasis by increasing systolic
BP
Cushings triad- systolic hypertension with a widening pulse pressure,
bradycardia, altered respirations
MEDICAL EMERGENCY
Factors Affecting Cerebral Blood Flow
o Carbon dioxide
High CO2-Relaxes smooth muscle, dilates cerebral vessels, decreases
cerebrovascular resistance, increases CBF
Low CO2- constriction of cerebral vessels, increases cerebrovascular
resistance, decreased CBF
o Oxygen
Less than 50mm Hg- cerebrovascular dilation, decreases cerebrovascular
resistance, increases CBF, increases oxygen tension
Extremely low oxygen- anaerobic metabolism, accumulation of lactic acid
Acidic environmentfurther vasodilation
o Cardiac or respiratory arrest, systemic hemorrhage, other disease states.

Increased Intracranial Pressure

Mechanisms of Increased Intracranial Pressure

o Increased ICPincrease in any of the three components in the skull.
o Common causes= mass, cerebral edema
o Sustained increases in ICP cause brainstem compression and herniation of the
brain

o Displacement and herniation of brain tissue= possibly irreversible

Herniationrespiratory arrest
Cerebral Edema
o Results in tissue volume that can increase ICP
o 3 types:
Vasogenic
Cytotoxic
Interstitial

Clinical Manifestations

Change in level of consciousness

Changes in vital signs
Ocular signs
Decrease in motor function
Headache
Vomiting

Complications

The major complications of increased ICP are inadequate cerebral perfusion and cerebral
herniation
o Tentorial herniation
o Uncal herniation
o Cingulate herniation

Diagnostic Studies

Computed tomography (CT)

Magnetic resonance imaging (MRI)
EEG
Cerebral angiography
ICP measurement
Brain tissue oxygenation measurement methods:
o LICOX catheter
Transcranial Doppler studies
Positron emission (PET)

Monitoring Intracranial Pressure and Cerebral Oxygenation

Indications for Intracranial Pressure Monitoring

o ICP should be monitored in patients with a Glasgow Coma Scale score of 8 or less
and an abnormal CT scan or MRI
Methods of Measuring Intracranial Pressure
o Ventriculostomy= gold standard
Directly measures the pressure within the ventricles
Facilitates removal and/or sampling of CSF
Allows for intraventricular drug administration.
o Fiberoptic catheter
Uses a sensor transducer to provide a direct measurement of brain pressure
o Subarachnoid bold or screw
Does not allow for CSF drainage
Ideal for patients with mild or moderate head injury
Easily converted into ventriculostomy
o Infection= serious complication
Factors contributing to infection
ICP monitoring more than 5 days
Use of ventriculostomy
CSF leak
Concurrent systemic infections
Assess insertion site
Aseptic technique
Monitor CSF drainage COCCA
o ICP= mean pressure
Drainage device should be closed for 6 minutes to ensure accurate reading.
Normal ICP P1, P2, and P3 resembles staircase
Report a mean increase in pressure or abnormal waveform to health care
provider
o Inaccurate ICP readings:
CSF leaks around monitoring device
Obstruction of intraventricular catheter or bolt
Difference between height of bolt and transducer
Kinks in tubing
Incorrect height of drainage system
Bubbles or air in tubing

Cerebrospinal Fluid Drainage

Physician orders level at which to initiate drainage and the frequency of drainage
(intermittent or continuous)
2 options: intermittent and continuous

o Intermittent- open ventriculostomy system at indicated ICP, allow CSF drain for 2
to 3 minutes, then close
o Continuous-requires careful monitoring to prevent removal of too much CSF
Place a sign above patients bed
Strict aseptic technique
Complications:
o Ventricular collapse
o Infection
o Herniation or subdural hematoma formation from rapid decompression

Cerebral Oxygenation Monitoring

LICOX brain tissue oxygenation catheter- measures brain oxygenation and temperature
o Continuous monitoring of pressure of oxygen in brain tissue (PbtO2)
Normal PbtO2= 20 to 40 mmHg
Lower than normalischemia
o Cooler brain temperatures produce better outcomes
Jugular venous bulb catheter- measures jugular venous oxygen saturation (SjvO2)
o Placed into internal jugular vein, catheter tip placed in jugular bulb
Placement verified by x-ray
Normal SjvO2= 55% to 75%
Less than 50%-->impaired cerebral oxygenation

Collaborative Care

Goals:
o Identify and treat the underlying cause of increased ICP
o Support brain function
o Maintain adequate oxygenation

Drug Therapy

Mannitol (Osmitrol) 25%- plasma expansion and osmotic effect

o Monitor fluid and electrolyte status
o Contraindicated if renal disease is present and if serum osmolality is elevated
Hypertonic saline solution- allows movement of water out of swollen brain cells and into
blood vessels
o Monitor blood pressure and serum sodium levels because intravascular fluid
volume excess can occur
Corticosteroids- treat vasogenic edema surrounding tumors and abscesses
o Not recommended for head-injury patients

o Complications: hyperglycemia, increased incidence of infections, GI bleeding

o Monitor fluid intake and sodium levels
o Perform blood glucose monitoring q6h
o Antacids, H2-receptor blockers, PPIs prevent GI ulcers and bleeding
Prophylactic seizure medications
Antipyretics
Sedatives
Barbiturates
o Monitor ICP, blood flow, and EEG

Nutritional Therapy

Hypermetabolic and hypercatabolic state increased need for glucose to fuel metabolism
Begin nutritional replacement within 3 days after injury
Feedings and supplements are guided by fluid and electrolyte status and metabolic needs
Evaluate urine output, insensible fluid loss, serum and urine osmolality, and serum
electrolytes
IV 0.9% sodium chloride for piggyback medications

Nursing Management Increased Intracranial Pressure

Nursing Assessment
o Neurologic assessment
Assess LOC using GCS
Three indications of response:
o Opening of eyes
o The best verbal response
o The best motor response
Highest score= 15, lowest score= 3
o Score of 8 or below= coma
PERRLA
Corneal reflex
Oculocephalic reflex (dolls eye reflex)
Dont use if cervical spine problem is suspected
Oculovestibular reflex
Motor strength
Palmar drift test
Bend knees in bed
Motor response
Dont use hand grip test
Vital signs

Be aware of Cushings triad

Diagnoses (SEE NURSING DIAGNOSES SHEET)
Planning
o Goals:
Maintain airway
Have ICP within normal limits
Have normal fluid, electrolyte, and nutritional balance
Prevent complications secondary to immobility and decreased LOC
Implementation
o Respiratory function
Maintain airway
Be alert to altered breathing patterns
Snoring sounds indicate obstruction
Remove secretions by suctioning as needed
Keep suctioning to a minimum
o Less than 10 seconds in duration
o Administer 100% o2 before and after
o Limit to 2 passes per suction
GCS of 8 or less or altered LOCintubation and mechanical ventilation
Elevate HOB 30 degrees
Prevent abdominal distention with NG tube
Contraindicated in patients with facial and skull fractures
Administration of symptom management drugs may alter neurologic state,
thus masking true neurologic changes
Opioids
o Rapid onset
o Minimal effect on CBF or oxygen metabolism
Propofol (Diprivan)
o Rapid onset
o Short half life
o SE: hypotension
Dexmedetomidine (Precedex)
o A2-adrenergic agonist for continuous IV sedation of
intubate and mechanically ventilated pt.
o SE: hypotension
Nondepolarizing neuromuscular blocking agents (Norcuron,
Nimbex)- complete ventilatory control of intracranial HTN
o Dont block pain, used with analgesics
Benzodiazepines are avoided
Monitor ABGs
o Fluid and electrolyte balance
Monitor IV fluids
Intake and output

Serum glucose, sodium, potassium, magnesium, osmolality

Monitor urine output to detect problems related to diabetes insipidus and
SIADH
Diabetes insipidus- decrease in ADHincreased UO,
hypernatremiasevere dehydration
o Tx: fluid replacement, vasopressin (Pitressin),
desmopressin acetate (DDAVP)
SIADH- excess ADHdecreased urine output, dilutional
hyponatremiacerebral edema, changes in LOC, seizures, coma
o Monitoring intracranial pressure
Body position
Head up position
Elevated HOB 30 degrees promotes drainage
Turn patient with slow, gentle movements
Prevent discomfort
o Avoid coughing, straining, Valsalvas maneuver
Avoid extreme hip flexion
Turn patient q2h
Passive ROM exercises
o Protection from injury
Restraints in agitated patient
Skin care under restraints
Light sedation
Have family members present
Prophylactic Antiseizure therapy
Padded side rails
Airway at bedside
Suction readily available
Antiseizure drugs
Quiet, nonstimulating environment
Touch and talk to the patient
o Psychological considerations
Anxiety
Short, simple explanations to patient and caregiver.