Increase Intracranial Pressure
Brain
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Brain tissue (1,400g)
Blood (75mL)
CSF (75mL)
Normal ICP 10 to 20 mmHg
Monro-Kellie Hypothesis
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Limited space for expansion in the skull, an
increase in anyone of the components
causes a change in the volume of the others.
Pathophysiology
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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.
Elevated ICP most commonly associated
with head injury
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Secondary Effects
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Brain tumors
Subarachnoid hemorrhage
Toxic and viral encephalities
Brain Tumor
Decrease Cerebral Blood Flow
Ischemia and Cell Death
Early Cerebral Ischemia
Vasomotor Stimulation
(brainstem)
Increase Systemic Pressure
(s/sx slow pulse, cheyne-stokes
resp.,elevated temp.)
Increase ICP
Diagnostic Findings
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Cerebral Angiography
Computed Tomography (CT) Scanning
Magnetic Resonance Imaging (MRI)
Positron Emission Tomography (PET)
Transcranial Doppler
Cerebral Angiography
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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
Computed Tomography Scanning
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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
Magnetic Resonance Imaging
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The first image shows
normal MRI result
The second image
shows with brain tumor
that causes increase
ICP
Positron Emission Tomography
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The first image shows
normal PET result
The second image
shows with brain tumor
that may lead to
increase ICP
Transcranial Doppler
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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
ICP Precautions
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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.
Manipulation of ICP
Blood
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Decrease cerebral metabolic demand
 sedation, analgesia, barbiturates
 avoid hyperthermia
 avoid seizures
Hyperventilation
 decreases blood flow to brain
 only acutely for impending herniation
Mannitol
Manipulation of ICP
Brain
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Mannitol
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dehydrate the brain, not the patient!
monitor osmolality
Hypertonic saline
Decompressive craniectomy
ICP Monitoring
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ICU patients who have sustained head trauma,
brain hemorrhage, brain surgery, or conditions in
which the brain may swell might require
intracranial pressure monitoring.
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The purpose of ICP monitoring is to continuously
measure the pressure surrounding the brain.
Why Monitor?
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Detect “events”
Manage intracranial pressure
Manage cerebral perfusion pressure
How?
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Ventriculostomy
Intraparenchymal fiberoptic catheter
Subarachnoid monitor
Useful adjuncts:
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Arterial line
Central venous line
Foley catheter
Manipulation of ICP
CSF
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External drainage
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therapeutic as well as diagnostic
technical issues
infectious issues
What to do with the
information...
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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
Indications for ICP monitoring
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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
Measure ICP
Management of
Raised ICP
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First Line
Rx
Maintain CPP>70 mm Hg
Raised ICP>25mm Hg
Ventricular Drain
Raised ICP>25mm Hg
Normal Vent/Oxygenation
Mannitol
Sedation
CT
Maintain CPP>70 mm Hg
Management of
Raised ICP
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Second Line
Rx
Raised ICP>25mm Hg
Furosemide
Chemical Paralysis
CSF Removal
Vasopressor
Raised ICP>25mm Hg
Barbiturates
Hyperventilation
Monitor SjO2
Nursing Process
The Patient with Increased Intracranial
Pressure
Assessment
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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
Nursing Diagnosis
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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
Planning and Goals
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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
Nursing Intervention
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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
Evaluation
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Maintained patent airway
Attains optimal breathing pattern
Attains desired fluid balance
Infection prevented
Complications prevented