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Raised ICP Nurses

1. Stabilize airway by intubating and start oxygen to address hypoxemia 2. Rapidly correct shock with fluid bolus and pressors to maintain adequate MAP 3. Control seizures by loading anti-seizure medications 4. Reduce ICP through sedation, head elevation, hyperosmotic therapy, and avoiding lumbar puncture given the low GCS

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47 views26 pages

Raised ICP Nurses

1. Stabilize airway by intubating and start oxygen to address hypoxemia 2. Rapidly correct shock with fluid bolus and pressors to maintain adequate MAP 3. Control seizures by loading anti-seizure medications 4. Reduce ICP through sedation, head elevation, hyperosmotic therapy, and avoiding lumbar puncture given the low GCS

Uploaded by

THONDYNALU
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Raised ICP

DR. JEWEL JOHN


Objectives:

 Pathophysiology and Evaluation of raised ICP

 Therapeutic options for raised ICP

 Approach to a comatose child

 Management of Status Epilepticus

 Brain Death and its Legal Aspects


Pathophysiology
& Evaluation of
raised ICP
14 -11 - 2017
pathophysiology

 The intracranial pressure & volume

 Within the skull, 3 non compressible


compartments contribute to ICP:

composition volume percentage


brain 1400 ml 80%
CSF 150 ml 10%
Blood volume 150 ml 10%
Total 1700 ml 100%
Intracerebral contents
ICP – Volume curve
cranio-spinal compensatory axis
Munroe - Kellie doctrine
ICP values

 Normal ICP varies with age

 Newborns ICP = 6 mm Hg and rises with age

 Adult ICP = 10 – 15 mm Hg

 ICP > 20 mm Hg is elevated


Cerebral Autoregulation
(Impaired in IC
pathology)
CPP & CBF
Variables that affect ICP

 MAP

 paCO2 – maintain 35 -45 mm Hg

 pO2 <60 mm Hg

 Cerebral metabolic rate – temperature /


seizures

 Hyperglycemia & hypoglycaemia


Causes of raised ICP

1. Increased brain mass:


Brain tumour
Cerebral edema – infections, trauma,
hypoxia
2. Increased CSF volume:
Hydrocephalus – congenital, infections,
hemorrhage
3. Increased blood flow:
vasodilatation – hypercarbia
Venous obstruction – thrombosis
A-V malformations
Signs & Symptoms of raised
ICP
 Headache, irritability
 Vomiting
 Depressed consciousness
 Cranial nerve palsy – VI
 Hypertension , bradycardia, irregular breathing
– Cushing’s Triad (late feature)

 Increased muscle tone, with brisk DTR


 Changes in pupil size
 Papilloedema
Management
of raised ICP
Complications
Tier one : Stabilization

 Airway : even if adequately breathing, early


intubation, ventilation and deep sedation are
indicated
 Indications for intubation –
 1. GCS < 8, or fall in GCS by 2 points
 2. Evidence of herniation
 3. airway compromise / irregular breathing
 4. Hypoxemia / hypercarbia
 Breathing:
 Circulation: Rapid correction of shock with NS &
inotropes to maintain MAP > 50 th centile for age
CPP targeted therapy

 CPP = MAP – ICP


 Maintain CPP > 60 mm Hg in adolescents,
> 50 mm Hg in 1 yr – 12 yrs
> 40 mm Hg in Infants
Calculate MAP target for the three age groups

(Clue: Raised ICP > 20 mm Hg)


CPP targeted therapy

 CPP = MAP – ICP


 Maintain CPP > 60 mm Hg in adolescents,
> 50 mm Hg in 1 yr – 12 yrs
> 40 mm Hg in Infants
Calculate MAP target for the three age groups
CPP = MAP + ICP
Infants MAP target = CPP + ICP = 40 + 20 = 60
Children MAP target = CPP + ICP = 50 + 20 = 70
Adolescents MAP target = CPP + ICP = 60 + 20 =
80
Management of raised ICP
Nursing pearls…CLUSTER
NURSING
 Hyperosmotic agents
 Mannitol, 3% saline
 CSF drainage with EVD
 Anti seizure medications
 LP IS CONTRAINDICATED IN CHILD WITH LOW
GCS
 Thiopentone coma
 Therapeutic hypothermia
Conclusion

 Patients presenting with altered mental status is


a medical emergency
 Systematic approach to stabilization and
diagnosis will be rewarding in majority
 Family needs to be counselled with honesty and
sensitivity
 Survival and long term prognosis difficult to
predict at the initial stages of illness
CASE SCENARIO

 10 year old child with h/o fever x 1 day


 Seizures x 1 day, multiple episodes
 Altered sensorium x 8 hours
 On examination,
 GCS E3V1M4, PEARL, Noisy breathing with
gurgling sounds. BP 70 / 40 mm Hg. SPO2 84%
 What are the management priorities?
 Maintain airway, start oxygen
 Fluid bolus -> Noradrenaline
 Intubate and sedate
 Load with phenytoin 20 mg/kg
 Maintain euthermia, paracetamol Q6H
 Maintain euglycemia
 Head in midline, cluster nursing, 3% Saline
 Antibiotics, withold LP
 Sedation before suctioning, oral care
 Prevent bedsores, early enteral feeds

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