Nicole JohnsonWhen caring for someone with increased ICP, here are some management strategies to think about! Here are very easy things you can do as a nurse to more complicated and emergent strategies!
| Positioning | – Keep HOB > 30 – 45 degrees – Keep head, neck, trunk midline – assess alignment – Straight legs – Decrease stimuli |
| Stool softeners | – Prevents straining and increasing intrathoracic pressure which = increased ICP |
| Pain | – Assess & treat pain; it is common in neuro injuries |
| Temperature management | – Normothermia – Avoid & treat fevers; lower core temperatures reduce brain metabolism & prevent secondary brain injuries |
| Airway management & Hyperventilation | – Airway protection – intubate if appropriate – Mild hyperventilation CAUTION! – Decreased CO2 causes vasoconstriction which leads to decreased cerebral blood flow! – Increased CO2 causes vasodilation. – Keep EtCO2/PaCO2 low normal 35 – 40 mm Hg; this is only possible if vented. |
| Pharmacological | Sedation: – Consider using short-acting sedatives such as propofol or dexmedetomidine (Precedex) if intubated Neuromuscular blockade (NMB) – Priority: Patients need continuous sedation first to reach RASS goal; also consider pain meds – Consider using the BIS monitor to target sedation levels! – Cisatracurium or vecuronium: PATIENTS MUST BE INTUBATED & SEDATED – Assess Peripheral Nerve Stimulation via Train of Four (see graphic below) – Goal is 1 – 2 twitches out of 4 – Barbiturates – Pentobarbital – Phenobarbital – Thiopental – Closely monitor for hypotension! Continuous EEG monitoring is often done with NMB or barbiturates because it is difficult to detect seizure activity! |
| Noninvasive ICP Monitoring | – Pupillometry – Noninvasive ICP waveform analysis – Transcranial Doppler – Optic Nerve Ultrasound – MRI/CT ***Some of these strategies are a snapshot of a patient’s ICP data, but might be good for patients who cannot have invasive ICP monitoring |
| Ventricular Drainage (EVD) | – EVD to manage hydrocephalus & drain excess CSF – You can get ICP measurements as well – cannot do continuous ICP monitoring because the drain should not be routinely clamped |
| Surgical Intervention | – Decompressive craniectomy – Used in refractory intracranial hypertension! – Used when other approaches have failed. |
| Osmotic Therapy | – Mannitol 20% Osmotic Diuretic – WORKS FAST 0.25 to 1 gram/kg IV bolus Decreases ICP in 5 – 10 minutes Max effect in 1 hour Use a FILTER – Hypertonic Saline Continuous infusion 2%, 3%, 5%* 7% (*central line required) Bolus 23.4% for neuro emergencies – Loop diuretics Decrease intracranial volume Survival TIPS – Monitor LABS! Osmolality, sodium & fluid status Osmo no higher than 320 mOsm/L (or as decided by a provider) Potassium levels with mannitol! – Monitor for rebound ICP – Keep CPP > 60 mm Hg*** – The CPP is more dynamic than we thought and the mean arterial blood pressure decreases 10 to 15 mm Hg before getting to the brain – Use CPPot if technology is available or transcranial doppler |
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References:
Intracranial Pressure Monitoring: Background, Indications, Contraindications
Evaluation and management of elevated intracranial pressure in adults – UpToDate
Management of acute moderate and severe traumatic brain injury in adults – UpToDate
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