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Neurological Emergency: Increased Intracranial Pressure (ICP)



Definition

Increased intracranial pressure (ICP) occurs when the pressure inside the skull rises, leading to compression of brain tissue, impaired blood flow, and potential brain damage. Normal ICP ranges between 5–15 mmHg. Any increase beyond this can disrupt cerebral perfusion and lead to neurological emergencies.

Causes

  1. Trauma:
    • Traumatic brain injury (TBI)
    • Skull fractures
  2. Infections:
  3. Neurological Disorders:
  4. Hydrocephalus:
    • Obstruction in cerebrospinal fluid (CSF) flow
  5. Bleeding Disorders:
  6. Others:
    • Hypoxia
    • High altitude cerebral edema (HACE)

Signs and Symptoms

  1. General Neurological Symptoms:
    • Severe headache
    • Nausea and vomiting (often projectile)
    • Altered level of consciousness (confusion, drowsiness, or coma)
  2. Vital Sign Changes (Cushing's Triad):
    • Hypertension with widening pulse pressure
    • Bradycardia
    • Irregular respirations
  3. Visual Disturbances:
    • Papilledema (swelling of the optic disc)
    • Blurred vision or double vision
  4. Motor and Sensory Abnormalities:
    • Hemiparesis or hemiplegia
    • Seizures
  5. Behavioral Changes:
    • Restlessness
    • Irritability
    • Personality changes
  6. Late Signs:
    • Fixed and dilated pupils
    • Decerebrate or decorticate posturing

Investigations

  1. Neuroimaging:
    • CT Scan: Identifies brain edema, hematoma, hydrocephalus, or mass lesions.
    • MRI: Provides detailed images of brain structures and abnormalities.
  2. Intracranial Pressure Monitoring:
    • Invasive methods like external ventricular drain (EVD) or fiberoptic devices measure ICP directly.
  3. Lumbar Puncture:
    • Rarely used; contraindicated in cases of suspected mass lesions due to risk of brain herniation.
  4. Blood Tests:
    • Complete blood count (CBC)
    • Coagulation profile
    • Electrolytes and arterial blood gases (ABGs)
  5. Electroencephalogram (EEG):
    • To detect seizures.

Medical and Surgical Treatment

Medical Management:

  1. Osmotic Agents:
    • Mannitol (hyperosmolar therapy) to reduce cerebral edema.
  2. Diuretics:
    • Furosemide for additional fluid reduction.
  3. Corticosteroids:
    • Dexamethasone to reduce inflammation (specific to tumors).
  4. Hyperventilation:
    • Temporarily lowers ICP by inducing cerebral vasoconstriction.
  5. Sedatives and Analgesics:
    • Propofol or midazolam to decrease metabolic demand.
    • Pain control with morphine or fentanyl.
  6. Anticonvulsants:
    • Phenytoin or levetiracetam to prevent seizures.
  7. Control of Blood Pressure:
    • Use of antihypertensives (e.g., labetalol) to avoid spikes in ICP.

Surgical Management:

  1. Decompressive Craniectomy:
    • Removal of part of the skull to relieve pressure.
  2. Ventriculostomy:
    • Drainage of CSF via an external ventricular drain (EVD).
  3. Evacuation of Hematomas:
    • Surgical removal of blood clots (e.g., subdural or epidural hematomas).
  4. Tumor Resection:
    • Removal of mass lesions causing pressure.

Nursing Interventions

1. Monitoring and Assessment:

  • Monitor ICP and vital signs frequently.
  • Assess for neurological changes using the Glasgow Coma Scale (GCS).
  • Check pupils for size, equality, and reaction to light.
  • Observe for signs of Cushing’s triad (hypertension, bradycardia, irregular respirations).

2. Positioning:

  • Elevate the head of the bed to 30 degrees to enhance venous drainage.
  • Avoid excessive neck flexion or rotation.

3. Fluid and Electrolyte Balance:

  • Monitor fluid intake and output.
  • Administer prescribed osmotic agents like mannitol.
  • Maintain normal serum sodium levels to prevent further edema.

4. Respiratory Care:

  • Maintain adequate oxygenation; administer supplemental oxygen if needed.
  • Perform suctioning carefully to prevent spikes in ICP.

5. Pain and Anxiety Management:

  • Administer prescribed sedatives and analgesics.
  • Create a calm, quiet environment to reduce stimuli.

6. Seizure Precautions:

  • Keep emergency equipment (oxygen, suction) at the bedside.
  • Administer anticonvulsants as prescribed.

7. Family Support:

  • Educate family members about the condition, interventions, and prognosis.
  • Provide emotional support and involve them in care decisions.

8. Prevent Complications:

  • Perform regular skin care and repositioning to prevent pressure ulcers.
  • Use DVT prophylaxis (compression stockings) to prevent blood clots.

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