Neuroscience Critical Care: Increased Intracranial Pressure

Neuroscience Critical Care

• This critical care area focuses on preserving neurological function in patients with central nervous system injuries.
• It combines interprofessional neurological expertise with general critical care.
• Acute and critical care nurses assess neurological conditions to detect deterioration.
• Nursing expertise optimizes patient outcomes in both critical care and neurosciences.

Increased Intracranial Pressure (ICP)

• The Monro-Kellie doctrine explains ICP, stating the skull volume is fixed and occupied by brain tissue, blood, and cerebrospinal fluid.
• If one component increases, the others must decrease to maintain equilibrium, known as intracranial compliance.
• Brain tissue is 80% water, while blood and CSF make up remaining 10% of intracranial contents.
• Compensation involves displacing CSF from the cranial vault through the foramen magnum.

Pressure-Volume Curve

• Phase A, intracranial pressure stays constant with increasing volume due to compensation.
• Phase B, ICP begins to rise with increasing volume, indicating decreasing compensation ability.
• Phase C, any added volume causes a sustained ICP increase and loss of compliance, leading to cerebral herniation.
• Cerebral herniation leads to brain tissue displacement and eventual brainstem compression and brain death.

Cerebral Herniation Syndromes

• Classified by the displaced tissue region.
• Cushing's triad symptoms occur late in herniation: increased systolic BP, decreased diastolic BP, bradycardia, and irregular respiration.
• A late sign of increased ICP is a unilateral fixed and dilated pupil.
• Uncal herniation involves temporal lobe displacement, compressing cranial nerve (CN) III and causing pupillary dilation.
• Motor paresis can be contralateral or bilateral, especially in central herniation.
• Abnormal flexor/extensor movements and plantar flexion (posturing) can occur.

Cerebral Edema

• Three types: vasogenic, cytotoxic, and transependymal, all impacting ICP.
• Vasogenic edema occurs when the blood-brain barrier (BBB) is disrupted.
• Cytotoxic edema involves cellular swelling without BBB disruption.
• Transependymal edema is caused by increased ventricular pressure, forcing CSF into brain tissue.
• Serial neurological assessments, including arousal, awareness, cranial nerves, and motor function, detect increased ICP.
• Decreased level of consciousness is the most sensitive indicator of increased ICP.
• Subtle changes in consciousness require establishing a baseline.

Intracranial Pressure Monitoring

• ICP can be monitored using catheters or sensors placed in brain ventricles or parenchyma
• ICP monitoring trends response to treatments
• Guidelines recommend ICP monitors for patients with traumatic brain injury (TBI) and Glasgow Coma Scale (GCS) scores of 8 or less
• Normal ICP ranges from 0 to 15 mm Hg ICP is typically treated if >22 mm Hg and individualized
• Cerebral perfusion pressure (CPP) is maintained above 60 mm Hg and calculated as MAP - ICP = CPP.

Cerebral Herniation Types

• Subfalcine herniation involves brain tissue shifting under the falx cerebri compressing the anterior cerebral artery potentially causing a stroke
• Manifestations include decreased consciousness, unilateral extremity weakness and pupillary changes
• Central herniation occurs when the diencephalon structures and tips of the temporal lobes shift downwards, compressing the brainstem, resulting in abnormal posturing and bilateral pupillary dilation
• Other central herniation symptoms include abnormal eye movements and coma
• Uncal herniation is when the temporal lobe shifts towards the midbrain, compressing CN III

Clinical Signs of Cerebral Injuries

• Unilateral dilated pupil
• Contralateral motor weakness or posturing
• Positive Babinski reflex
• Coma
• Tonsillar herniation involves the cerebellar tonsils descending through the foramen magnum damaging the medulla, resulting in abnormal posturing.
• Other tonsillar herniation symptoms include bilateral pupillary dilation
• Cerebral edema occurs due blood-brain barrier disruption
• Brain tumors can disrupt the BBB, releasing vasogenic endothelial growth factor (VEGF)

Cerebral Treatment

• Vasogenic Edema treatment includes osmotic therapy and hyperventilation
• Cytotoxic Edema treatment interventions are the same as for vasogenic edema
• Transependymal Edema is treated with cerebrospinal fluid drainage

Expanded Orientation Questions

• What state are you in right now?
• What city are you in right now?
• What kind of place are we in right now?
• What floor are we on right now?
• Why are you here today?
• What are your children's/family members' names?

Increased ICP vs Cerebral Herniation

Increased Intracranial Pressure

• Level of consciousness is Progressive confusion and increasing lethargy
• Pupillary assessment is Sluggish reaction and ovoid shape

Cerebral Herniation

• Level of consciousness is Unresponsive
• Pupillary assessment is Unilateral or bilateral pupillary dilation

ICP Monitoring

• Intraparenchymal probes are inserted into the white matter, typically frontal lobes of the brain
• ICP-monitoring devices possess has less drift and improved measurement accuracy over time
• External ventricular drain (EVD) or ventriculostomy may be connected to a filled transducer system
• The EVD catheter tip is placed into one of the lateral brain ventricles using external landmarks
• EVD catheters are placed under sterile conditions and they are connected to an external drainage system
• The drainage of CSF is controlled by raising or lowering a collection burette

Cerebrospinal Fluid Drainage

• Cerebrospinal Fluid Drainage involves interdisciplinary interventions to reduce VAI such as clip hair instead of shaving and maintain a closed drainage system
• VAI has been reported as high as 11.4 infections per 1,000 catheter days
• Maintain transparent dressing, replace only when nonocclusive or soiled to help reduce VAI
• Most EVDs have scales printed on the device allowing measurements in millimeters of mercury, if the drainage burette is set to 5 mm Hg while leveled at the external auditory meatus
• CSF will drain when ICP reaches 5 mm Hg and for safe use, EVDs are flushed with preservative-free normal saline
• Routine dressing changes are avoided to maintain the system is closed to prevent infection

Intracranial Pressure

• Values may not always be representative of ICP in all brain areas because edema can cause higher pressures
• Proper leveling of the drainage system (0 point) is at the external auditory meatus, ICP Waveform produces three waves
• Cases of decreased intracranial compliance mean the P2 wave is elevated above the P1 and P3 waves

Interprofessional Management

• Reducing intracranial volume reduces brain, blood, or CSF volume.
• Initial approach: Airway management and osmotic diuretic administration and hyperventilation.
• Continuous neurologic monitoring is critical.
• Emerging bedside monitoring includes brain tissue oxygenation and digital quantitative pupillary assessment

Radiographic Imaging

• CT scans are required to determine collection of blood
• Laboratory testing is necessary to guide medical treatments and the volume of water in brain tissue observed in cerebral edema is reduced by increasing the osmolality of the blood in cerebral edema treatment
• High-concentration sodium chloride solutions used to pull water from the interstitial space
• IV fluid should be administered to replace losses of systemic dehydration

Diagnostic test used during management

• Reducing Thickness reduce Cross-Sectional imaging increase detail the lower portion of the Cerebellum medulla visualized with an mri
• Ct scans are commonly performed for Critically Ill patients, and Ct Scan First visualized without injecting I V Contrast determine the cause of bleeding Contrast material is injected.
• Transport of A Patient with High icp is Challenges for the right time
• If expecting to receive contrast, assess and evaluate Kidneys and Creatine

Ct Scans In Radiation

• Pregnancy is assessed before CT scans and shielded
• Claustrophobia is assessed for claustrophobia
• In cases where patient cannot lay flat, assess ability to lie flat
• Assess patients or shell fish allergies to IV contrast agents
• If you get a CT , A Large Gauge I V is required
• MRI (magnetic resonance imaging) Requires Planning
• MRI requires cardiopulmonary monitoring change from regular monitor

MRI Restrictions

• Patients and Staff must be screened for metal
• There are various types of medical equipment you cannot bring into an MRI due to magnetic Field
• In electrical activity in different regions of the cerebral cortex
• EEG is a neurologist provides the Official tracing

EEG Restrictions

• A patient must completely still for an Eeg to avoid artifact
• If patient is moving a lot provide sedation to reduce movement artifact
• During continuous EEG, inspect the head so all the electrodes are in check
• Blood tests are used to monitor blood diuretic levels and cause cerebral edema
• A sample must be drawn every 1-2 hours
• Monitor sodium serum because they cause Cerebral Edema
• Ensure sodium levels don't rise by over 10 mEq in 24 hours, can cause Central Pontyne

Inspection For Care

• Inspect for crystal use Filter
• 2016 the Brain Trauma for not using Osmotor
• Compare Healthcare for Adverse effect/benefits
• Steward symptom are Acute stroke and exclusion with Hemorage
• The bed must tilted at 45 degrees
• Position the neck inline with the hip, facilitates in blood

Stroke

• It includes turning side to side or light flat
• ICP level and compliance should be high
• Nurse can evaluate patients
• Reduce stimulation will improve brain
• Section to create room to swell
• Vigilant

Assessments

• Oxygenation
• Ventilation Hemodynamic
• Full System
• Negatives impacting with increased Icp
• Decreases lead to renal failure
• Patients under barbiturates uses Eeg
• Neurological

Complications

• Changes BP
• Decreases heart rate
• Widening Pulse pressures and changes in respiratory patterns
• Patients have secure airways reduce oxygen levels
• Informs if sedation goals
• It is needed to treat paid

Side Effects

• Propofol has Side effects, and you should advocate
• Is to achieve desired to treat
• For medication
• If have bad Gag , must have Clear airways clear.
• Thermoregulation Damage damage to Hypothalamus
• Family is interrupted from life
• Decreasing the risk that can secondary
• Is necessary to show injuries such as Low Consciousness signally change quickly.
• Hypertension can result in more injuries
• Low sodium causes hypertonic saline, serum levels causes brain to increase
• Artial Sample are important to help, End Tracheal needs to be known the amount and head level check the arterial, check is it midline ,
• Reduce pressure with 100 percent oxygen

Stroke Epidemiology

• Every for seconds and it results in 6 Millions live
• Stroke 7% cause and 10% lch , 3% Aneurysm
• Stroke is cause due to hYPERTENSION and followed by smoking and cocaine
• Large vessel Lvo and small vessel Emobilc

Additional Stroke Events

• Tia is temporary and clinic similar like ischemic stroke and last minutes for 24 hours which results for Fibrin
• Can determine tissue image TIA are based over resolution diagnosis and is lack on tissue

Initial Stroke Steps

• EMS Crew alert Transport, ED staff notes the stroke
• Stewart exam and 22 points indicate problems
• Blood are check to reveal No Lch , so IV is checked and is arranged with results

The Stroke Path

• Sudden Block which result lower in the arey which causes clinical manifestations
• Blood flow is disrupted damage Irriversible such as tissue myocardial and also area to be
• Target and therapy, abrupt brain is also the heart function
• Large vessel occur if broken which causes clots then to form which can vessel
• Depend to larger area such as proximal Distal

Common Stroke Conditions

• Weakness right face, decrease Right side
• Dysphasia if left face
• In attentional right
• Diziness

Stroke Intervention

• Emobilizitation in the heart and poor atril fibrillations
• Valve that is irregular, which consist left ventricle
• Stroke patients check if they have Coagulation disorders

Initial Testing

• Hypercoagulation is cause stroke under 55 Y
• Stroke patient assess by mri it’s super sensitive and the Doppler and scan and echocardiogram and lab as well
• Blood cerebral by open are reverse by clot

Administration of IV

• Irt Pal restore neural tissue use in patient in acute stroke is currently to be one use treatment

Irt Pal

• Is 3-4 Hours symptoms with 30 to over a decrease with strict, a another is into arterial
• Damage the air
• Combination therapy, traditionally providers that specialized

Traditional Providers

• Is neurologists and are emerging and medical centers or joints centers
• Primary Centers Offer over iv center
• The Therapeutic windows has the largest in areas

Stroke Interventions

• Must have measurable deficit with NIHA Time of the Normal for the IV are within 4 hours otherwise
• Is greater must have greater age 80, and receive medication and stroke in the past
• Overlapping the blood vessels to dilate when bp to a systolic goal
• And for a specific risk has to go after antiplatelet therapy
• Alpelete helps cleaves body,
• Bind to to degrade colts and the patient is being monitored closely

Stroke Anti Hy Pertensives

• Labetalol to beta blockers the system vascular blood pressure without causing change
• Hydralazine is direct to cause blood level vasodilation with less pressure to treat
• Reduce in heart rate but are used correctly and always teach the patient
• CT is checking if causes signs show with the ischemic first
• Test are helpful and venous and they may for some
• VTE help prevent
• CEREBLAL to the the reduce with the

Stroke Causes

• Stroke is ischemiac and its due to Low Oxgen area of blood
• Patients response will give to be 30 to 35 degrees with blood levels by prevent reeding or give more time the
• Regular or in what care such as increase the area that the stroke is
• Aspiration is needed and should perform
• Check the fluid for balance in SAH

Complications Of Stroke

• Blood and is cause is ischemiac from that blood which cause the blood to sprain
• Intracellulsr is over due In adequate Oxygen supply if disrupt can increase ICP
• Risk for for Lungs, and facial
• Stroke can weakness the with a risk for the Contractions and neglect
• Hemorric strokes are AVM and it usually from weaked spot
• Patients may lost conicsesnes but that is linked with location
• There are stages to the h and h grading test for hemorrhage

Stroke Evaluations

• Aneurysm and will cause be difficult so get Mri right right a way
• Traumatic SAH as direct disruption or blood to reduce volume flow in the tissue
• Monitor if ischemiac is present and reduce Bp.

Head And Brain Safety

• Head must be stabilized well
• Patients need support for emotions
• Head must not be high or low should be to standard or causes damage

Neurogenic Shock

• Neurogenic shock is distributive causes vasodilation and causes hypovolemia which needs rapid correct or results
• Is causes by body disfunctions but will use atropine and or if needed heart pacing
• Patient will need continue support such as fluid, bp . HR or levels
• With low Vaso, given sympathy medication such as as Midrodiene.
• Neurogenic can go result in high bp then to low to low

Injury Brain Trauma

• Injury Brain are classify be Gcs like mild , moderate to severe
• Head, Scaplp .skuil.brain,,etc.. and may need more then or have Epidural as injuries such Contusion
• For airway manage which be hyPOtension

Skull FRACTure CARE

• Skull must be Inspect and palpate from Irregularities
• The skull, opned is associated disrupted but and closed
• Skuil fractures are non dis[laced but radiographly with
• Fragmented is sharp and irregular but can tear dural mater

Procedures to elevated

• Elevation to stabilize titatuim screws to visualize the dural must be damage the skull
• Base has a breach of the the dura and cnerve with bllodo vessels to tranverse
• Penetrating or be result of bullet or knife
• Concusson head force that strikes damage which is no show but can cuase energy at cells

Areas Of damage

• Contusion is superficial that cuases blood damage or hematomas
• With cerebral. Often monitore frequent by neuro to decline to know the brain damage
• Damage the artery. That helps keep the brain groove in intact
• Blood collects inside and outside for the sKuII but Dure is still Connected
• Speed causes rapid to the ics and is typically need be take in check or can cuase major Damage
• Subdural is to the veins which causes blood to to disrupt in the spcaing, speed to vascular and or smaller with disrupt. - Subarachnoid- a bleed tissue

Neurons Injury

• Axonal Injury Causes Rotational force which Direct to Axon , swelling ,
• Inhibit the netwokrs
• There needs be CT, but sometimes show after for sometime
• The base is call basilar fracture such damage which causes fluid and blood ,
• Hematoma occur when collection from base to be skull

Arterial Dissection

• Arterila may happen to the neck with mechanical trauma
• Can rupture the blood
• Causes horner such Triad

Interprofession Management

• The management of the is to manage ,Icp promotion
• Lcp monitor needs to be be kept
• There of course in are is and also Bp levels
• And is need in case for heart or infection or high low Sodium levels

SAH (subarachnoid hemorrhage)

• If have A Tbi (traumatic brain injury) Must have have be sure to assess
• Elevate the head to drain
• Csf leak monitor fluid if it drains
• Ng tubes will cause and brain fracture
• The goals is for interal nutriotn for 71 hours

In TBI (traumatic brain injury)

• Normothermics to prevent energy
• Precautions for a seizure clear out area and meds
• If they show or need and to give something
• Ensure the VTA with compressions to prevert clot

TBI Goals

• Suiccnit inform if have
• TBI
• The the the
• Know about a good support

Neuogenic

• Is a decrease blood level function level so that cause low BP,Brady C,or Hypothermia
• If does have a stroke then it may for sometime not

I hope these notes help you in your studies!