INCREASED INTRACRANIAL PRESSURE

BOX THEORY
Think of the skull as a large closed box that cannot expand. In this box is brain tissue (85%), blood (7%), and
cerebrospinal fluid (CSF) (8%). Intracranial pressure (ICP) is the force exerted by the three components within
the skull and is measured by the pressure of the CSF.

The normal range for ICP is approximately: 80-180 mmH2O or 0-15mmHg.

The contents within the rigid skull “box”, must remain relatively constant or the pressure will increase. To
compensate for any sustained increase in pressure the brain can cause certain components to decrease, but
this compensatory function is limited (Monro-Kellie Hypothesis).

• Ordinarily the body keeps ICP within safe limits although normal fluctuations do occur in response to
physiologic factors such as:
o 1-Respiratory Rate Changes
o 2-Body positioning – posture
o 3-Increased intra abdominal pressure
o 4-Intrathoracic pressure – Coughing, sneezing, straining

To maintain a constant cerebral blood flow despite these normal fluctuations in ICP the body employs
2 mechanisms:

PRESSURE AUTOREGULATION

o Brain with constant blood flow – CPP – How much pressure it takes to perfuse the brain
o Cerebral Perfusion Pressure = Mean Arterial Pressure – Intracranial Pressure
o (CPP=MAP-ICP) Normal Range 60-150mmHg CPP – This is how much pressure it takes to
. keep the brain perfused
o MAP= Systolic – Diastolic + Diastolic
3
• Mean arterial pressure must be at least 50-60mmHg higher than ICP to maintain adequate CPP.
• CPP <50mmHg – irreversible neurological function and decreased cerebral perfusion.
• Pressure atuoregulation maintains CPP regardless of fluctuations in systemic blood pressure.
• If B/P increases the cerebral vasculature vasoconstricts to protect the brain from blood engorgement
• If B/P decreased the cerebral vasculature vasodilators to increase the blood supply to the brain.
• Pressure autoregulation system fails when ICP rises > 33mmHg and cerebral blood blow varies
passively with systemic blood flow.

METABOLIC AUTOREGULATION
• Cerebral blood vessels also dilate and constrict in response to CO2 and O2 levels in blood
• Cushings Response – Seen with decreased cerebral blood flow. The brain, in attempt to restore blood
flow, Increases arterial pressure to overcome increased ICP
o Cushings Triad = Bradycardia, HTN, Bradypnea CO2 is a potent vasodilator

• Hypercapnia (PCO2 >50) Trigger vasodilatation to increase

• Hypoxemia (PO2<50) Oxygen supply to the brain
These auroregulatory mechanisms maintain constant cerebral blood flow but do nothing to reduce
ICP. Both of these systems fail in the presence of  ICP.
COMPENSATION / DECOMPENSATION
Once the 2-autoregulatory systems have failed the body goes into compensation/decompensation cycle.

 1-Small volume increase is better compensated than large volume increase

 2-ICP increase over long periods of time are compensated better than rapidly increased ICP
o 50cc of blood in brain is a massive bleed.

• Compensation – Cerebral Spinal Fluid Regulation
o Decreased Production
o Increased Reabsorption
o Displacement
 Dura of Spinal Cord
 Foramen of Luschka
 Foramen of Megendie
CSF cushions the brain and spinal cord
-CSF is produced in the Chorion plexus and is
reabsorbed in the Arachnoid villi.
-You have about 100-150cc of CSF circulating at any
given time. You produce about 20ml per hour.
-It replenishes it self

• If the pressure continues to increase and the CSF can no longer compensate, decompensation
begins with compromise of the cerebral blood flow.

• Decompensation – Venous compression with arterial flow continuing to perfuse the brain
resulting in an increase in ICP resulting in a decrease in CPP resulting in:

 Cerebral Blood Flow

Increased ICP Cerebral Hypoxia (O2)

DECOMPENSATION
CYCLE
“killing itself off”

Cerebral Edema  CO2;  PO2;  PH

Acidosis

Vasodilatation

Venous system collapses and the arterial continues to pump to brain increasing blood supply,
which increases ICP and Decreases CCP.

• If the cycle of decompensation continues, the brain will do one of two things.
o Herniate downward
o The brain will no longer be perfused usually resulting in death.
• Examples of Herniation: Tentoriam – Keeps the cerebrum
from sitting on the cerebellum
SUPRATENTORIAL Foramen Magnum – The opening
at the base of the skull
• Herniation above the Tentoriam and is moving down
• Putting pressure on the brain stem

INFRATENTORIAL
• Herniation Below the tentoriam
 • Will not move up. May begin as a Supratentorial herniation and move downward.
• Eventually the brain stem is crushed against the bony opening of the base of skull
CAUSES OF INCREASED INTRACRANIAL PRESSURE
INCREASE IN BRAIN SIZE
Handwritten notes begin
• Edema here and are also in
• Tumor packet
• Infection
• Bleeding
• Foreign body (bullet)
• Abscess
• Metabolic (diabetic ketoacidosis) – 1st change is in LOC – because the brain controls it

ICREASE IN INTRACRANIAL BLOOD VOLUME

• Aneurysm
• Subarachnoid hemorrhage
• Venous flow blockage – Trach ties, turning head, too many pillows
•  CO2 – triggers vasodilatation of  O2 supply to brain
• Hyperthermia

INCREASE IN CEREBROSPINAL FLUID VOLUME

• Meningitis
• Subarachnoid hemorrhage
• Tumors Ventricles

SIGNS AND SYMPTOMS OF INCREASED ICP

DETERIORATION IN LOC
• The First thing you see
• RAS System
• Decreased O2 Levels
Response to Painful Stimuli
MOTOR AND SENSORY LOSS Purposeful response – if you are doing pressure to nailbeds
• Motor Cortex – Medulla and they pull away.
• Sensation: numbness, tingling Nonpurposeful response – if you put pressure on the nail bed
• Motor: Paralysis and they go into a Decerebrate posturate.
• Posturing – Only seen in comatose clients
o Decorticate: cerebral cortex has been affected
 Extension of the lower extremities and flexion of the lower extremities
• Core of the body (Core – Cortex – Decorticate)
o Decerebrate: Brain stem has been affected – Worst because of brain stem injury
 Extension of the lower and upper extremities
 Stem – Decerebrate - Extension
o Flaccidity – Rag doll – Very Bad
 • (Nail beds, sternal rub)

HEADACHE
• Compression on arteries, veins, cranial nerves
• Brain Tumor: Worse in the morning
• Increased ICP Progressively worse

PUPILLARY CHANGES
• Cranial nerve III(Brain Stem) - Dilated, sluggish = herniation at tentorial notch Do not use a flashlight

PAPILLEDEMA
• Swelling optic disc
o S/S: deplopia and decreased visual acuity Waley/Wong P. 984
• Choked Disc trunk – or the edges are not real clear INFANTS
-Tense bulging fontanels
VOMITING -Separating cranial sutures
-Macewen’s Sign – Crackpot
• Pressure on vagus nerve, brain stem, medulla the cranial sutures separate
• Increased ICP sudden onset with no nausea -Setting sun – The eyelids
• Projectile look as they are setting over
the eyes them selves
-High pitched cry
ALTERATIONS IN VITAL SIGNS -Infant that cant be soothed
• The last thing seen -Look for changes in behavior
o Blood Pressure
 Increased Systolic with diastolic volume remains around same with widening
pulse pressure
o Pulse
 Bradycardia – Pump slower more effective perfusion overcome high pressure
o Respirations
 Depends if the medulla is affected
 Typical Decrease with apnea due to pressure on medulla
o Temperature
 Increase 105-106oF
 Cooling blankets, Tylenol

MEASURING AND MONITORING INCREASED ICP

OBSERVATION
• Neuro checks – should be repeated as much as needed
• Altered LOC

LUMPAR PUNCTURE
• CSF Pressure, Measure ICP
• Cause Herniation with  ICP
o Can cause herniation by producing a lower pressure area
• Increased r/f infection

CONTINOUS INTRACRANIAL MONITORING

• Ventricular Catheter
P. 1637
 • Subarachnoid Screw
• Epidural Sensor
• Fibra

MEDICAL MANAGEMENT OF INCREASED INTRACRANIAL PRESSURE

VENTILATION

• Effective short term

• Open airway
• Hyperventilation – short term
• Position max airway, suctioning (with hyperventilation before)

CEREBRAL PERFUSION PRESSURE CONTROL

• Increase HOB 30o, neck neutral midline position

• Blood Pressure should be Normotensive
• Temperature control
• Neck neutral, midline position

MECHANICAL DECOMPRESSION
• Ventricalostomy - drainage device to drain CSF – aseptic technique
•  R/F Infection
• Must maintain 1” above ear

DRUGS
• Osmotic diuretics: Mannitol, D50W
o Makes the intravascular (hypertonic) draw fluid from the interstitial into the intervascular spaces. You are
duiresing tissue
o Given for rapidly rising ICP
o Possible complications: Pulmonary edema (Listen Breath sounds), CHF
o THERAPEUTIC EFFECT: Improve LOC – Given because they have an altered LOC caused by a neuro
problem. They will have Increased Urine output but that is not the therapeutic effect.

• Diuretics Lasix
o Usually given in conjunction with Mannitol to help clear out the intravascular volume
o THERAPEUTIC EFFECT: Decrease Peripheral Edema

• Corticosteriods – Decadron
o If you have a patient with some kind of cerebral thing going on and they are not on Decadron or some
type of steroids or osmotic diuretic then as a nurse you would question the order
o If on Decadron they should also be on some type of gastric med: Axid, Pepcid, Tagamet
o Will mask S/S of infection
o Would not DC abruptly

• Barbiturate (drug induced coma)

o If you have a person in a drug induced coma the patient is totally dependent on you as a nurse for
everything.

• Anticonvulsants: Dilantin, Phenobarbital, Cerebryx

o If a person has cerebral trauma – the blood irritates the brain leading to seizure
o At high risk for injury
 o DO NOT prevent seizures only help control seizures

INTRACRANIAL SURGERY
• Tumor
o Get out the tumor
• Craniotomy – Injury, infection
• High risk – unstable patients
NURSING MANAGEMENT
ESTABLISH AND MAINTAIN A CONTINUED / ACCURATE DATA BASE

PROMOTE REDUCTION OF THE CEREBRAL EDEMA AND INCREASED ICP

• Administration of osmotic diuretics

o D50W & Mannitol
 Dehydrate brain, reduce cerebral edema
 Hypertonic thus draws fluid out of brain tissue
 Assess breath sounds

• Administration of corticosteroids
o Dexamenthasone
 Reduce edema surrounding brain tumors when tumor cause increased ICP

• Promote venous drainage

o Increase HOB, Head neutral and midline

• Prevention of activities that increase intracranial pressure

o Lifting, straining, coughing, bending

• Fluid restriction
o Increase BV = Increase ICP

PREVENT HYPOXIA AND HYPERCAPNIA

• Observe for clinical manifestation of ventilatory impairment

o Respirations

• Monitor blood gases

o Hypercapnia trigger vasodilation  O2 to brain

• Administer Oxygen

• Maintain patent airway and improve ventilation

• No narcotics or sedatives
o  respirations and  LOC

• Prevent and/or treat elevated temperature

VENTRICULAR DRAINAGE

CONTINOUS INTRACRANIAL MONITORING

PROMOTE SEIZURE CONTROL

PROMOTE OVERALL GOOD BASIC NURSING CARE AND PREVENTION FROM INJURY

PROVIDE EMOTIONAL SUPPORT

From another set of handwritten notes

NURSING INTERVENTIONS
• Maintain patent airway
o Suction with care B/C I ICP (hyperoxygenate)
o Auscultate lung fields
o HOB
• Attaining Normal Resp Pattern
• Preserving / Improving Cerebral Tissue Perfusion
o Head neutral, midline position
o Use cervical collar
o  HOB
o Avoid Hip flexion
o Maintain calm environment

ASSESSMENT OF  ICP
• Obtain hx events leading to present illness / subjective data
• Mental status
• LOC – Sensitive indicator of neurologic function
• Cranial nerve function
• Cerebellar function – Balance and coordination
• Reflexes
• Motor / sensory function
• Pupil checks
• VS
• Glasgow Coma scale – Eye opening, verbal response, motor responses
• Periorbital edema (may interfere with eyes)
• Orientation to person, place time
• Motor Responses: Spontaneous, Purposeful movement, Movement only response to noxious
stimuli, abnormal posturing
o Cannot respond to command: apply painful stimulus (firm, gentle pressure)
• Flaccidity – Most severe neurologic impairment

PLANNING / GOALS
• Maintain airway
• Normalization resp.
• Adequate cerebral tissue perfusion  ICP
 • Restoration of fluid balance
• Absence of infection
• Absence of complications

WHY?
INCREASED INTRACRANIAL PRESSURE
Frequent neuro checks. Why?
• Condition quickly changes and establish a baseline. Looking for improvements
Drug Induced Comas. Why?
• Decreases metabolic demand on brain
• Shut down
Avoidance of Valsava Maneuver. Why?
• Increased ICP
Administer Lasix. Why?
• Decreases ICP (unload intravascular spaces)

Hyperventilation. Why?
• Respiratory alkalosis  Cerebral vasoconstriction  Decreased cerebral blood volume, decreased ICP
• O2 and  CO2 levels

Seizure Precautions. Why?

• Cerebral changes cause seizures

Elevate HOB. Why?

• 20-30o will increase venous return/drainage.

Careful regulation of IV fluids. Why?

• Prevent Increased ICP. DO NOT want to overload with fluids

Neck in Neutral, Midline Position. Why?

• Promote venous drainage

Administer Oxygen. Why?

• Increase cerebral perfusion

Administer osmotic diuretics. Why?

• Dehydrate brain, Decreases cerebral edema

Passive Range of Motion. Why?

• Prevent Contractures

Turn and deep breathe. Why?

• Prevent pneumonia

Administer corticosteriods. Why?

 • Decreases cerebral edema

Treat elevated temperatures. Why?

• Increases cerebral metabolism rate and cerebral edema

Restrict fluids. Why?

• Dehydration

Check stools for occult blood. Why?

• Corticosteroids can cause bleeding
Administer Anticonvulsants. Why?
• Prevent convulsions

Monitor intake and output. Why?

• Dehydration, diabetes insipidus

No trendelengerg. Why?
• Decreased venous return and increases cerebral edema

Monitor electrolytes. Why?

• Evaluate seizures
Keep blood pressure normotensive. Why?
• Increase BP  Increased ICP
Monitor BUN/Creat Levels. Why?
• Renal Function
Monitor Blood Gas Values. Why?
• Respiratory Status (CO2)
Continuous intracranial pressure monitoring. Why?
• Condition of client
Administer stool softeners. Why?
• Prevent straining
Ventriculostomy. Why?
• Drain, and administration of drugs
Intracranial surgery. Why?
• Remove tumor, correct bleed

Nothing snug around neck. Why?

• Decreases venous drainage
Avoid Extreme hip flexion and prone position. Why?
• Increased intraabdominal/ intrathoracic pressure increases ICP
Assist client to move in bed. Why?
• Movement increases ICP
No Restraints. Why?
• Resistance Increases ICP
Decrease anxiety level and avoid emotional upsets. Why?
 • Decreases ICP
Suction as needed to maintain clear airway. Why?
• Coughing Increases ICP

No Narcotics or sedatives. Why?

• Effects LOC