Download Increased Intracranial Pressure and Monitoring

Increased Intracranial Pressure and Monitoring
Increased Intracranial
Pressure and Monitoring
This course has been awarded two (2) contact hours.
This course expires on February 28, 2019.
Copyright © 2007 by RN.com.
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First Published: February 23, 2007
Revised: February 28, 2016
RN.com is accredited as a provider of continuing nursing education by the American
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Increased Intracranial Pressure and Monitoring
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Increased Intracranial Pressure and Monitoring
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Increased Intracranial Pressure and Monitoring
Acknowledgements
RN.com acknowledges the valuable contributions of...
Nadine Salmon, RN, BSN
Shelley Polinsky BSN, RN, CCRN
Kelly Muck, MPH
Suzan Miller-Hoover DNP, RN, CCNS, CCRN
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Increased Intracranial Pressure and Monitoring
Purpose
The purpose of Increased Intracranial Pressure and Monitoring is to present information
regarding intracranial hypertension and its effects on patient outcomes.
To understand intracranial hypertension, it is important to understand the
pathophysiology of intracranial pressure and how an elevated intracranial pressure
relates to a patient's clinical signs and symptoms.
This course will review intracranial monitoring, monitoring devices, and treatments for
intracranial hypertension. The importance of documentation related to monitoring and
treating intracranial hypertension as well as relevant patient and family education will be
covered.
Learning Objectives
Upon successful completion of this course, you will be able to:
1. Describe intracranial physiology and assessment.
2. Identify intracranial hypertension pathophysiology.
3. Define intracranial pressure and cerebral perfusion pressure.
4. Describe the dangers of an elevated intracranial pressure.
5. Describe the signs and symptoms of rising intracranial pressure.
6. Define intracranial pressure monitoring and the indications for a ventriculostomy.
7. Identify the five methods of intracranial monitoring.
8. Describe the treatments of intracranial hypertension.
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Increased Intracranial Pressure and Monitoring
Introduction
Intracranial pressure refers to the pressure within the intracranial vault (skull).
Elevated intracranial pressure (ICP), or intracranial hypertension, can occur as a
complication of neurosurgical emergencies including traumatic brain injury (TBI), or
intracranial hemorrhage, or from medical illnesses, such as meningitis or fulminant
hepatic failure (Luks, 2009).
Early recognition of elevated ICP, use of invasive monitoring, and the initiation of
therapies designed to reduce ICP and address the underlying cause, are important to
improving morbidity and mortality outcomes.
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Increased Intracranial Pressure and Monitoring
Anatomy
Ventricular system
Four ventricles comprise the ventricular system within the brain, the largest of which
being the two lateral ventricles. These lateral ventricles are situated deep within the
subcortical tissue one on each side of the midline.
Each lateral ventricle communicates with the third ventricle through the foramen of
Monro. The third ventricle communicates with the fourth ventricle, located in the
medulla, through the aqueduct of Sylvius. The floor of the fourth ventricle is continuous
with the spinal canal. Any blockage within this system will result in some degree of
hydrocephalus and increased intracranial pressure.
Cerebral Spinal Fluid (CSF)
Cerebral spinal fluid is a modified form of plasma consisting of water, glucose, protein,
minerals and a few lymphocytes; which, is produced by the choroid plexus of the two
lateral ventricles at a rate of approximately 10-15 mLs per hour or 500 mLs per day
(Bone & Lindsay, 1997). This fluid flows through the subarachnoid space and is
absorbed into the venous system via the arachnoid villi. The normal amount of CSF
found in the brain and spinal column is approximately 100-150 mLs; this remains
constant as long as the production rate of CSF equals the absorption rate. If an
obstruction occurs anywhere in the system, hydrocephalus occurs and results in a rise
in intracranial pressure (ICP) due to the continued production of CSF.
CSF functions:
 Providing buoyancy and support to the brain and spinal cord
 Maintaining a constant extracellular fluid composition for central nervous system
metabolic activity
 Providing a medium for unnecessary substances and metabolites removal (Bone
& Lindsay, 1997).
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Increased Intracranial Pressure and Monitoring
Intracranial Pressure Concepts
Unlike other organs in the body, the brain is encased in a rigid structure. This structure
protects the brain from injuries that might occur while performing the activities of daily
living.
However, the contents within the skull, brain, blood, and CSF are incompressible.
Hence, if one of the components increases in volume or mass, an overall increase in
pressure within the skull occurs unless another component decreases by the same
volume or mass –Monroe-Kellie Doctrine (Hazinski, 1999).
Brain:
Blood:
CSF:
80%
7-10%
7-10%
Brain Volume Issues
Cerebral swelling – increase or maldistribution of cerebral blood flow (excessive blood
flow to some areas of the brain within 24-48 hours after head trauma)
Cerebral edema – increased water content
Cerebral Circulation Facts
 The brain requires approximately 18% of the total body oxygen content and 25%
of the cardiac output.
 Cerebral venous return must match cerebral arterial flow
 The blood-brain barrier:
o Is freely permeable to water
o Is not adequately developed in infants
o Protects the brain from fluctuations in acid-base balance and toxic agents
o Increases in serum glucose levels increase the amount of water crossing
the barrier into the brain
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Increased Intracranial Pressure and Monitoring
Test Yourself 1
Elevated ICP levels result when a decrease in the volume of one or more components
is offset by a volume reduction/displacement in some other component.
a. True
b. False
Elevated ICP levels result when an increase in the volume in the volume of one or more
components cannot be offset by a volume reduction/displacement in some other
component.
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Increased Intracranial Pressure and Monitoring
Factors Influencing Cerebral Circulation
Cerebral circulation is an essential part of normal brain function. Changes in cerebral
circulation in conjunction with a traumatic head injury can exacerbate the injury resulting
in a longer hospitalization and/or decreased mortality and morbidity.
Cerebral circulation is affected by cerebral perfusion pressure, arterial and venous
blood flow; and cerebral compliance.
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Increased Intracranial Pressure and Monitoring
Cerebral Perfusion Pressure (CPP)
Cerebral perfusion pressure is the difference between the cerebral arterial pressure and
the ICP.
However, it is not easy to routinely measure cerebral arterial pressure. Therefore, in
order to estimate the CPP the following calculation is utilized:
CPP = MAP – ICP
(MAP = mean arterial pressure)


A CPP greater than 70 mm Hg (adults) or 50 mm Hg (pediatrics) is required for
effective cerebral perfusion
o CPP less than 50-70 mm Hg results in hypoperfusion, anoxic encephalopathy
and possibly cardiac arrest
o CPP greater than 150 mm Hg results in hyperperfusion, cerebral edema and
cerebral encephalopathy
Cerebral perfusion is determined by blood flow, not blood pressure
o A normal CPP does not guarantee effective cerebral perfusion especially in
the presence of hypertension and clinical deterioration.
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Maintain Cerebral Blood Flow
In order to maintain an effective cerebral perfusion pressure, cerebral blood flow must
be maintained. The body’s autoregulation process plays an essential part of regulating
cerebral blood flow. Additionally, alterations in oxygen tension levels, carbon dioxide
levels, and metabolic factors affect cerebral blood flow.
Factors Controlling Cerebral Blood Flow (CBF)
Pressure autoregulation:
A constant cerebral blood flow is maintained
regardless of changes in systemic blood pressure
Metabolic autoregulation:
CBF must adapt as the oxygen and metabolic
needs of the brain increase or decrease
Arterial oxygen tension:
CBF increases when PaO2 is less than 50-55 mm
Hg
Arterial carbon dioxide:
CBF increases when PaCO2 increases
Metabolic alterations:
CBF increase when potassium, calcium, hydrogen
ions, cytokines, adenosine, or nitric oxide
increases
Factors Controlling Dilation Of Cerebral Arteries
 Severe hypoxemia (PaO2 less than 50-55 mm Hg)
 Tissue hypoxia
 Acidosis
 Hypercarbia (increases in PaCO2)
Factors Controlling Constriction Of Cerebral Arteries
Hypocarbia (decreases in PaCO2)
Alkalosis
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Increased Intracranial Pressure and Monitoring
Cerebral Compliance
Cerebral compliance is the ability of the intracranial contents to tolerate an increase in
volume without increasing ICP and compromising the brain and cerebral blood flow.
The brain is able to compensate for short term increases in ICP; however, this
compensation is limited and if the cause of the increased ICP is not managed,
progressively smaller changes in volume will significantly increase the ICP.
A non-compliant brain is stretched to its maximum and no longer has elastic
properties, therefore increasing the risk of herination.
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Intracranial Pressure Management Concepts
Normal ICP ranges from 4-15 mm Hg
Intracranial hypertension: ICP greater than 20 mm Hg for longer than 5 minutes
ICP is the pressure exerted by the intracranial contents and can be increased by
anything that acutely increases venous pressure, for example: suctioning, coughing,
valsalva maneuvers, and lying down from a sitting position.
The patient’s positioning has an effect on ICP. Patients should be positioned in bed with
their head and neck in midline position and the head of the bed up 30-45 degrees so as
not to impede venous return.
Special Circumstances
Open fontanels, sutures, cranial fractures or a surgically placed bone flap allow the
brain to increase in size without increasing the ICP significantly. These openings in the
skull act as a “pop-off valve” lowering the pressure that might otherwise cause
intracranial hypertension.
Did You Know?
Fontanel size and tenseness may indicate increased ICP with or without a monitoring
and drainage device in place
Increased size and tenseness in the presence of a drainage device may indicate a nonfunctional drain especially in the event of an intracranial hemorrhage
Increasing head circumference in the presence of a bone flap or open cranial fractures
may indicate increased ICP with or without a monitoring and drainage device in place
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Test Yourself 2
ICP levels of greater than 20 mm HG for longer than 5 minutes is called
_______________.
Answer: Intracranial hypertension
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Increased Intracranial Pressure and Monitoring
Causes of Increased ICP
Common causes of increased intracranial pressure include any dynamic that cause
changes in the cranial vault volume (CSF brain volume, or blood).
Increased Cerebrospinal Fluid Volume
 Non-obstructive hydrocephalus: CSF absorption rate is less than the CSF
production rate
 Obstructive hydrocephalus: CSF is unable to pass from the cranium to the spinal
cord
 Pseudo tumor cerebri
Increased Blood Volume
 Acidosis
 Increased right atrial pressure
 High arterial PaCO2
 Dural sinus thrombosis
Increased Brain Tissue Volume
 Ischemia and necrosis
 Infection
 Hemorrhage
 Tumor
 Cytotoxic edema
 Vasogenic edema
(Copstead & Banasik, 2005)
Nursing Alert: Tracheal suctioning has also been linked to increased intracranial
pressure, and thus should only be performed when absolutely clinically necessary and
with close monitoring of the patient before, during, and after the procedure (Moore &
Woodrow, 2009). Interventions that reduce the cough reflex, such as lidocaine lavage
prior to suctioning, should be considered.
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Increased Intracranial Pressure and Monitoring
Signs & Symptoms of Elevated ICP
Patients with increased ICP often present with headache, nausea, vomiting, and
progressive decline in their level of consciousness. Intracranial hypertension exhibits
significant decreased level of consciousness and pupillary changes.
Sustained intracranial hypertension usually results in a reduction in cerebral blood flow
(CBF) and increased potential for brain herniation. Herniation, the movement of the
brain tissue downward often results in death.
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Increased Intracranial Pressure and Monitoring
The Glasgow Coma Scale
The gold standard for accessing the status of a patient with a traumatic brain injury is
the Glasgow Coma Scale.
While newer tools are being developed and implemented, this course will only discuss
the Glasgow Coma Scale.
The Glasgow Coma Scale is only a portion of the neurological assessment. This scale
measure the cognitive brain function.
The score is based on the patient’s best response to stimulation and does not designate
muscle strength or symmetry. The scale assigns a numeric value to a patient’s
neurologic response to specific variables.
There are two scales, one for patients under 2 years of age and the other for patients 2
years and older.
The Glasgow Coma Scale can be utilized with acute and chronic patients. It is important
to obtain a baseline score in order that changes can be readily identified and treated.
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Increased Intracranial Pressure and Monitoring
Glasgow Coma Scale Scoring
A score of 3 is the lowest (worst) response and 15 is the best (no deficit)
A score between 9-12 correlates with moderate injury
A score of 8 or lower correlates with severe brain injury and is the threshold for
intubation and ventilation
Glasgow Coma Scale for Age Greater Than 2 Years
Eye Opening
Verbal Response
Motor Response
Spontaneously
To speech
To pain
None
Oriented
Confused
Inappropriate
Incomprehensible
None
Obeys commands
Localizes to pain
Withdraws from pain
Abnormal flexion to pain
Abnormal extension to pain
None
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Total score
Glasgow Coma Scale for Age Less Than 2 Years
Eye Opening
Verbal Response
Motor Response
Spontaneously
To speech
To pain
None
Babbles, coos appropriately
Cries but is inconsolable
Persistent crying or irritable cry
Grunts or moans to pain
None
Spontaneous
Localizes to pain
Withdraws from pain
Abnormal flexion to pain
Abnormal extension to pain
None
4
3
2
1
5
4
3
2
1
6
5
4
3
2
1
Total score
Did You Know?
A change in the total GSC of 1-2 indicates a change in the patient’s condition and
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Increased Intracranial Pressure and Monitoring
should be reported to the medical provider. For example: a patient with a score of 10
on your last exam now has a score of 8; indicates that the patient’s condition is
deteriorating. Conversely, if the score gets higher, the patient is improving.
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Increased Intracranial Pressure and Monitoring
Cushing’s Triad
Cushing's triad refers to a classic presentation which is caused by intracranial
hypertension.
Patients who are not monitored with an ICP monitoring device should be assessed for
Cushing’s Triad symptoms serially. Cushing’s triad may cause focal neurologic deficits
that develop from mass lesions or herniation.
Hypertension
Respiratory
depression/
disordered breathing
Bradycardia
The triad is identified as the presence of hypertension, bradycardia, and
respiratory depression/disordered breathing.
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Increased Intracranial Pressure and Monitoring
Test Yourself 3
What are the three signs of Cushing’s Triad that indicate that the pressure in the brain is
increasing?
a.
b.
c.
d.
Hypotension, hypoventilation, bradycardia
Hypertension, disordered breathing, bradycardia
Hypertension, hypoventilation, tachycardia
Hypotension, disordered breathing, tachycardia
Rationale: Cushing's triad refers to a classic presentation of increased ICP/intracranial
hypertension. The triad is identified as the presence of hypertension, bradycardia, and
respiratory depression/disordered breathing.
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Increased Intracranial Pressure and Monitoring
Traumatic Brain Injury
ICP monitoring is often recommended in patients with traumatic brain injuries.
Research indicates ICP monitoring can contribute to improved patient outcomes.
Literature also provides an evidence base for the use of ICP monitoring when
intracranial hemorrhage is suspected in patients with a severe head injury, particularly
those who are comatose.
The Guidelines for the Management of Severe Head Injury recommends ICP monitoring
in comatose head injury patients if the Glasgow Coma Score (GCS) is 3-8 and an
abnormal CT scan.
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Increased Intracranial Pressure and Monitoring
The Use of ICP Monitoring
Continuous intracranial pressure monitoring is the gold standard for assessing
intracranial hypertension as it measures the pressure in the brain directly and in some
circumstances is combined with cerebral spinal fluid drainage to remove the excess
fluid accumulation (Mayer & Chong, 2002).
Indications for ICP Monitoring
Some of the indications for ICP monitoring include:
 Intracranial hemorrhage
 Cerebral edema
 Severe traumatic brain injury
 Post-craniotomy
 Space-occupying lesions such as hematomas, abscesses, tumors or aneurysms
 Encephalopathy from hypertensive crisis, lead ingestion, or liver failure
 Meningitis/encephalitis that causes malabsorption of CSF
(NIH, 2012)
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Increased Intracranial Pressure and Monitoring
Five Standard Methods To Monitor ICP
Subarachnoid screw / bolt (provides continuous ICP data)
Subdural/epidural catheter (provides continuous ICP data)
Intraparenchymal fiberoptic catheter (provides continuous ICP data)
Ventriculostomy catheter (provides intermittant ICP data and drainage)
Ventriculostomy placement of a dual use catheter (intraparenchymal technology for
continuous monitoring and continuous drainage capabilities): newest technology
(Chin, 2014)
There are unique risks and benefits to each of the five monitoring devices.
1. Subarachnoid Screw
The subarachnoid screw, also known as a bolt, is placed into the skull, via a burr hole,
abutting the dura.
The positives of this method are that infection and hemorrhage risks are low.
The negative aspects include the possibility of ICP overestimation, misplacement of the
screw, and occlusion by debris.
2. Subdural/Epidural Catheter
The subdural/epidural catheter is placed into the epidural space which is less invasive
but also less accurate. It cannot be used to drain CSF; however, it can be used to
evacuate blood from the epidural space. Because this catheter does not enter the brain,
there is a lower risk of infection (Zhong, Dujovny, Park, Perez, Perlin, & Diaz, 2003).
3. Intraparenchymal Fiberoptic Catheter
The intraparenchymal fiberoptic catheter is the second most accurate way to obtain an
ICP. The tip of this catheter rests in the intraparenchymal tissue and can measure ICP
as well as brain temperature. There is no way to drain CSF, but infection and
hemorrhage rates are low.
4. Ventriculostomy
The ventriculostomy, interventricular catheter or drain is a soft tube placed through a
burr hole into the lateral ventricle of the brain. This catheter has the ability to drain CSF
and intermittently measure the ICP when connected to a standard transducer set which
is never pressurized.
In most settings ICP monitoring is only allowable when the drain is off; some systems
allow both to be open at the same time. However, if the drainage catheter becomes
clogged, ICP cannot be measured.
(Zhong et al., 2003).
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Increased Intracranial Pressure and Monitoring
5. Ventriculostomy Placement of a Dual Use Catheter
The ventriculostomy placement of a dual use catheter is a soft tube with two lumen
placed through a burr hole into the lateral ventricle of the brain. One lumen allows
drainage for the CSF the other lumen allow for continuous ICP monitoring via a fiber
optic tip.
Complications of a ventriculostomy include:

CSF leakage

Air leakage into the subarachnoid space or ventricle

Overdrainage of CSF leading to ventricular collapse and herniation

Underdrainage of CSF leading to increased intracranial pressure

Inappropriate therapy related to ICP readings with dampened waveforms,
electromechanical failure, or operator error such as inappropriate leveling
(NIH, 2012)
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Increased Intracranial Pressure and Monitoring
Test Yourself 4
The device that allows continuous drainage and monitoring of ICP is:
a.
b.
c.
d.
e.
Subarachnoid screw / bolt
Subdural/epidural catheter
Intraparenchymal fiberoptic catheter
Ventriculostomy catheter
Ventriculostomy placement of a dual use catheter
Rationale: The ventriculostomy placement of a dual use catheter is a soft tube with two
lumen placed through a burr hole into the lateral ventricle of the brain. One lumen
allows drainage for the CSF the other lumen allow for continuous ICP monitoring via a
fiberoptic tip.
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Increased Intracranial Pressure and Monitoring
ICP Waveforms
Normal Waveform
A normal ICP waveform generally has 3 distinct components, P1, P2, and P3. If the
waveform is dampened, the patency of the catheter may be compromised. (Kocan, M.
J., 2002).
ICP Waveform Analysis
Normal Waveform
P1
Percussion wave
 First peak, sharp,
consistent amplitude,
largest peak
 Originates from the
choroid plexus
pulsations in the
ventricles
P2
Tidal or Rebound wave
 Second peak, variable
in shape and amplitude
 May become largest
wave in the presence of
decreased compliance
(increased
swelling/edema)
P3
Dichroitic wave
 Third peak, smallest
 Reflects aortic valve
closure
 Pressure decreases
to diastolic baseline
Poor Compliance Wave Form
Poor Compliance – increased swelling, edema, and loss of elasticity
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Dampened Wave Form
Dampened Waveform – air/clots/tissue in pressure tubing
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Abnormal Waveforms
A Waves
ICP Waveform Analysis – Abnormal
A waves – plateau waves – spontaneous, rapid, irregular increase in ICP (50-100
mm Hg) lasting 5-20 minutes.
These waveforms are always pathological. This represents impaired cerebral blood
flow and occurs with decreases in blood pressure associated with hypovolemia.
Clinical signs: changes in respiratory patterns, pupil dilation, abnormal pupillary
response, sweating, flushing, headache, vomiting, and bradycardia.
B Waves
B waves – sharp, rhythmic increase in in ICP (20-50 mm Hg) lasting 30 seconds to 2
minutes. This wave is related to changes in vascular tone, respirations, A waves, and
occur during headaches, seizures, posturing, and decreased level of consciousness
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Increased Intracranial Pressure and Monitoring
C Waves
C- waves are clinically insignificant small waves that occur every 4-8 minutes and
result from fluctuations in systemic pulse and respirations
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Increased Intracranial Pressure and Monitoring
Troubleshooting Waveforms
Examine the drainage tubing distal to the patient for the presence of air bubbles, clots,
or tissue. If any are present, flush the tubing away from the patient to remove the debris.
Check for kinks in the tubing and to ascertain if the clamps and stopcocks are open.
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Increased Intracranial Pressure and Monitoring
Assisting With Insertion of The Catheter
A neurosurgeon places the ventriculostomy catheter. The area of the head where the
catheter will be placed may be shaved or a small amount of hair may be clipped to
reveal the insertion site.
The nurse monitors the patient and assists the neurosurgeon as appropriate.
IMPORTANT: The ventriculostomy catheter should be filled with normal saline that has
no bacteriostatic preservative.
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Increased Intracranial Pressure and Monitoring
Monitoring Intracranial Pressure
According to American Association of Critical Care Nurses Procedure Manual (2011),
the head of the patient’s bed should be consistently elevated to 30-45 degrees for
measurement. The transducer should be leveled to the Foramen of Munroe to achieve
consistency in measuring ICP (Luks, 2009).
Commonly used reference points are:
 The imaginary line between the top of the ear and the outer canthus of the eye
(the point at which the upper and lower eyelids meet)
 The tragus of the ear (the tag in front of the opening of the ear)
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Increased Intracranial Pressure and Monitoring
Drainage
The nurse should monitor the CSF drainage at least hourly for amount, color, and clarity
of drainage. Draining the CSF can be performed continuously or intermittently.
Normal CSF is clear and colorless.
Drainage System Precautions
 Decrease the risk of central nervous system infection by using aseptic technique
when assembling, manipulating, or accessing the fluid-filled monitoring system.
 Use only sterile 0.9% NaCl to fill the pressure tubing and never heparinized
solution.
 Maintain tight connections.
 Assure patient alarms are on at all times.
 Never use a flush device for ICP monitoring.
 Keep the system free of air to ensure maximal accuracy.
 Maintain proper leveling and zeroing of the system.
 Use extreme care when turning or positioning the patient to avoid accidental
disconnection of the tubing.
 Keep the drainage cylinder upright to avoid getting the filter in the drainage
system wet.
 Keep the stopcock to the drainage system closed when performing pressure
monitoring (affects accuracy).
(NIH, 2012)
Did You Know?
Newer drainage systems can be laid flat due to a change in design.
The stopcock on the transducer set may be open to the drainage systems without
altering the accuracy of the newer systems.
Be sure to read the directions on the system your facility uses and be cognizant of any
changes with the system.
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Increased Intracranial Pressure and Monitoring
Intracranial Hypertension Treatment
The goal of treatment is to return the ICP to normal: ICP <20 mmHg and CPP between
60 and 75 mmHg (Luks, 2009).









Decrease patient stimuli whenever possible
Draining CSF is the gold standard treatment of high intracranial pressure and
intracranial hypertension
Maintain the head of the bed at 30-45 degrees
Maintain the patient’s head midline avoiding hyperextension or flexion of the neck
Sedation or pain control
o Barbiturate coma may be utilized with the goal to lower the metabolism
rate, oxygen consumption, and CO2 production of the brain
Fluid management
o Diuretics, hyperosmolar diuretics or hypertonic saline may be considered
o Goal serum osmolarity of 300-320 mOsm/L and serum sodium of 140-150
mEq/L (Luks, 2009).
Blood pressure management
o Vasopressors
o Vasoconstrictors
o Goal to maintain adequate cerebral perfusion pressures
Body temperature management
o One degree decrease in temperature produces approximately 7%
decrease change in the overall metabolic demand
o Avoid shriving, as this can increase metabolic requirements
PCO2 level management
o Maintain PC02 about 30 mmHg
o Lower PCO2 levels cause vasoconstriction, which may cause cerebral
ischemia
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Increased Intracranial Pressure and Monitoring
Test Yourself 5
Managing ICP includes all of the following except:
a.
b.
c.
d.
Fluid management: keeping the serum osmolarity at 300-320
Keeping the PCO2 less than 30 mmHg
Keeping the head midline and straight
Avoiding temperatures that cause shivering
Rationale: Maintain PCO2 levels about 30 mmHg; lower PCO2 levels cause
vasoconstriction, which may cause cerebral ischemia
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Increased Intracranial Pressure and Monitoring
Documentation





ICP and CPP
CSF description
Waveforms
Treatment and outcomes
Assessment
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Increased Intracranial Pressure and Monitoring
Family Considerations
Family and significant others are encouraged to visit as family interaction is important to
positive patient outcomes.
Family members often feel the need to stimulate the patient, to get a response that had
not been elicited since the injury; therefore, it is essential that family members be
educated regarding when it is safe to stimulate their loved one.
When the ICP is unstable, maintaining a quiet environment and minimizing stimulation
is essential to the patient’s care.
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Increased Intracranial Pressure and Monitoring
Case Study 1
Johnny B. a 22 year-old motocross professional was competing in a practice race when
his bike had a malfunction. Johnny flew off the bike and onto the track. He is
unconscious at the scene. Upon arrival to the trauma center, he has a decreased level
of consciousness, his blood pressure is 180/90, HR 50 and his respiratory rate is 14.
You alert the physician and tell him what?
You suspect a traumatic head injury with increased intracranial pressure.
During your assessment you score the Glasgow coma Scale as a 8/15.
You anticipate what treatment for Johnny and why?
A GCS of 8 indicates a severe head injury and you anticipate intubation and mechanical
ventilation to control the CO2 levels, placement of an intracranial pressure monitoring
and drainage device.
Opening pressures were 18 and his mean arterial pressure was 92. What is his
cerebral perfusion pressure?
CPP is 74 which is low normal.
Based on this CPP, ICP and arterial pressure, what treatment do you anticipate?
Place HOB up 30-45 degrees, whichever is most appropriate to his condition, assure
that his head and neck are in a midline position and not extended or flexed and maintain
a quiet environment.
Johnny’s family and friends are anxious to see him; what will you educate them
on?
Acquaint them with the monitoring systems, what elevated ICP means and how it is
treated and how to keep stimulation to a minimum.
As Johnny progresses, his GCS score rises to 13 and his ICP is 10-12. You
determine he is Improving or deteriorating?
Improving
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Case Study 2
Marybeth was in a car accident as an unrestrained passenger. Upon impact, she was
ejected.
She has been in the ICU for the past 3 days when her ICP is sustained at 24 and her
CPP is 50. Her drain is open at 10 and draining.
What treatment do you anticipate?
Marybeth is exhibiting signs of intracranial hypertension with poor perfusion, and
despite draining CSF her ICP is not responding. She may need diuretics or hypertonic
saline to lower her ICP. If she is in pain, she may need pain medications or she may
require a medically induced coma to reduce the ICP.
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Increased Intracranial Pressure and Monitoring
Conclusion
Increased ICP or intracranial hypertension is a life threatening condition that must be
treated quickly to reduce the risk of brain injury or death.
Numerous treatment modalities are available for the healthcare worker. Knowing and
using these modalities increases the probability of positive patient outcomes. Finding
the fine line between normal hemodynamics, effective cerebral perfusion pressure, and
ICP management is essential in caring for these patients.
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References
At the time this course was constructed all URL's in the reference list were current and
accessible. rn.com. is committed to providing healthcare professionals with the most up to date
information available.
American Association of Critical Care Nurses. (2011). D. L. Wiegand, & K. Carlson,
Eds. AACN Procedure Manual for Critical Care (6th ed.). Elsevier Saunders: St. Louis.
American Association of Neuroscience Nurses Clinical Practice Guideline Series
(2011). Care of the Patient Undergoing Intracranial Pressure Monitoring/ External
Ventricular Drainage or Lumbar Drainage.
Bone, I. & Lindsay, K. (1997). Neurology and Neurosurgery Illustrated. (3rd ed.) Elsevier:
Atlanta.
Chin, L. (2014). ICP Monitors. Medscape Reference. Retrieved from:
http://emedicine.medscape.com/article/1983045-overview#aw2aab6b3
Copstead, L., & Banasik, J. (2005). Pathophysiology. (3rd Ed.). pp.1099. Saunders: St.
Louis.
Hazinski, M. F., Hedrick, C., & Bruce, D. (1999). Neurologic disorders, Manual of
Pediatric Critical Care, Mosby: St. Louis, p. 371-445
Kocan, M. (2002). Ask The Experts. Critical Care Nurse, 22, pp. 70-73.
Luks, A. (2009). Critical Care Management of the Patient with Elevated Intracranial
Pressure. Critical Care Alert, September 2009, P. 44-48.
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Mayer, S. & Chong, J.Y. (2002). Critical care management of increased intracranial
pressure. Journal of Intensive Care Medicine, 17(2):55-67.
Moore, T. & Woodrow, P. (2009). Nursing Care, Observation, Intervention & Support for
Level 2 Patients. (2nd ed.). New York: Routledge.
Trauma.org. (n.d.). Neurotrauma: Cerebral Perfusion Pressure.
Zhong, J., Dujovny, M., Park, H., Perez, E., Perlin, A., & Diaz, F. (2003). Advances in
ICP Monitoring Techniques. Neurological Research, Volume 25, p. 339-350.
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