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Raised Intracranial pressure

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by

Tejas Shah

on 23 December 2012

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Transcript of Raised Intracranial pressure

Mx of Raised ICP – Gen measures If volume of any of the compartments increases/addition of extra volume
There has to be compensatory decrease in
volume of the other 2
i.e. Cerebral oedema, Tumour etc


If there is problem with compensation, ICP rises Outcome asso. with raised ICP Treat overt seizures
Prophylactic Anticonvulsants in cases of focal pathology i.e. SDH/Parenchymal bleed

If sudden changes in vital signs with no overt manifestations – High suspicion of seizures Seizure Mx Indications in raised ICP


Tumour – pre/post-operatively
TBME Steroids Painful stimulus e.g. cannulation/catheterization/bl sugar testing

Discomfort e.g suctioning

General noxious stimulus e.g. loud noises/bright lights/talking loudly/monitor noises/ventilatory alarms etc Sedation/Pain relief When autoregulation is lost ?

In this situation, goal should be to maintain

CPP = MBP – ICP

Ideal situation – direct ICP reading
In our step-up – mostly we will try to keep MBP above certain range Cerebral perfusion pressure CPP Goals of Mx Normal intracranial pressure
Adults 5-15 mm Hg
Infants/Children < 10 mm Hg Skull has fixed volume (except babies!)
Contents:
Blood 7-10%
Brain 80%
CSF 7-10% The Monro-Kellie Doctrine Case scenario 3 Preferably Neuro-ICU
Team Mx involving
Pediatric Intensivist
Neurosurgeon
Neurologist
Physiotherapist
Not forgetting – Critical care nurses Ideal place to manage

Not ideally defined – though most neurosurgeons would say 48-72 hours of strict neuroprotection How long to continue neuroprotective measures? Helpful in refractory/unresponsive cases of raised ICP

Significant risk of myocardial depression and hypothermia

Agents – Pentobarbitol/Thiopentone Barbiturate coma Preferable to use Volume-controlled/PRVC mode
To achieve adequate Tidal & Minute volume (Set TV 6-7 ml/kg, adjust as per ABG/EtCo2)

Avoid high PEEP > 8
Fio2 adequate to maintain saturations in normal range (>92%)
Rate – age appropraite Mechanical Ventilation Brain Herniation Types of Herniation Case scenario 1 Dr Tejas Shah
Consultant Pediatric Intensivist
CIMS Hospital
M.D. (Pediatrics)
Pediatric Intensive Care Medicine (UK)
Fellowship in Pediatric Bronchoscopy (USA) Raised Intracranial Pressure ICP Monitoring by ICP Bolt
CSF Withdrawal by Ventricular drain Drainage of EDH/SDH
Insertion of shunt in Hydrocephalus with raised ICP
Re-siting VP shunt for blockage
Removal or decompression of mass

CSF Withdrawal by ventricular drain Surgical Mx of Raised ICP Prophylactic or prolonged use is not recommended Helps in acute rise in ICP and works very fast
Intubation and manual hyperventilation
Aim to reduce pCO2 to 30-35 mm Hg

It works by causing cerebral vasoconstriction
Double-edged sword

Prolonged hyperventilation – causes cerebral ischaemia Hyperventilation Don’t forget – Idiopathic Intracranial Hypertension Causes of raised ICP Trauma e.g. RTA, Accidental/Non-accidental injuries

Brain – Increase brain volume
Infection/trauma/electrolyte imbalance/HIE
Metabolic/Hepatic Encephalopathy

CSF Alterations e.g. Hydrocephalus
Increased production
Decreased absorption
Pathway obstruction

Cerebrovascular Alterations
Hypertension
Vein of Galen malformation etc
Tumors They help in accurate measurement of ICP and gives dynamic overview Ventricular pressure monitoring - EVD
A Cathetar is inserted thru burr hole into lateral ventricle
Is attached to fluid-filled (or fibre-optic) monitoring system ICP Monitoring devices They help by shrinking brain tissue that has not been damaged Mannitol (20%)
0.25 – 0.5 g/kg (= 1.2 – 2.5 ml/kg) bolus
Can be repeated 6 hourly if needed
Osmotic diuretic – caution in patients with low MBP


3% Saline
3-5 ml/kg bolus over 10-20 minutes
Can be repeated as needed
Target to achieve Na 150-155
Useful in low BP scenarios Hyperosmolar Therapy Following Stabilization/ABC Mx –
Neuroimaging is indicated to
Guide further management Gradual
Behavioural changes
Headache
Vomiting
Visual disturbances/diplopia
Polyuria etc

Sudden
Depressed consciousness
Convulsions
Coma
Cardiorespiratory changes Symptoms asso. with ICP Subfalcine - Midline shift - Brain herniates below Falx

Transtentorial/Uncal - uncus on medial aspect of temporal lobe herniates through tentorium - occulomotor nerve compressed – presses on midbrain

Foramen magnum/Tonsillar – cerebellar tonsils forced down into foramen magnum – compression of medulla Case scenario 2 Reducted attenuation of Rt Temporal lobe MRI - Bilateral temporal changes Rt>Lt Fig. 1: Autoregulation of cerebral blood flow in a normal brain and in the ischemic penumbra (the tissues surrounding the ischemic core after a stroke). Cerebral autoregulation Case Scenarios
Define raised ICP
Cerebral autoregulation and CPP
Causes
Methods to measure
Management
Outcome data Objectives: First do no harm
Resuscitation & Stabilization
Prevent secondary brain insults
Reverse/Rx primary brain insult if possible e.g. EDH/SDH/Hydrocephalus/Tumours etc Admit to PICU
If GCS <8 -- Intubate and ventilate
30 degrees head up
Head in neutral position

Temp control - normothermia/avoid hyperthermia
Normoglycaemia
Normocarbia/Hypocarbia Physical Stimulation: Stress response
Systemic vasoconstriction

BP and CBF increased

Raised ICP If there has been blood loss in RTA - fluids/blood

If low cardiac output suspected - Dopamine

If normal Cardiac output on assessment
Add Nor-Adrenaline Subarachnoid screw pressure monitoring
Subarachnoid screw or ICP bolt is inserted thru burr hole
Into sub-arachnoid space
Is attached to fluid-filled (or fibre-optic) monitoring system Normothermia/Avoid Hyperthermia Normocarbia/Hypocarbia Euglycaemia (cc) photo by medhead on Flickr CPP Crit Care Med 2011 Duration of raised ICP is more imp

Acute rises in ICP if brought done quickly is not as harmful
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