Management of Raised ICP

Jon-Paul Chamoun

Case studyLittle Jimmy

24 year old male presents to ED post footy tackle with severe headstrike associated wth loss of consciousness 1 minute. - GCS 14 at the scene- Sore head-On examinationHR 85 reg. BP 130/80 RR 22 36.8CVS, Abdo, Resp NADNeuro: PEARL UL + LL Normal Tone Power Reflexes Sensation and Coordination

Tea Break!Beep Beep

‘Hi Dr, please review little Jimmy. Drowsy ++’

Crap, I missed the SSSM Neurosurg topics!

Little Jimmy..NowHR 40 BP 180/90 RR 8 36.8

Drowsy+++Eyes crossedPupils dilated…

PANIC = Neurons not firing

RIP Little Jimmy

A bad referral leads to…

The drainage

PhysiologyInside the rigid Vault (~ 1500mls)

- Brain (80%)- Blood (10%)- CSF (10%)

Intracranial PressureNormal : <15mmHg (adults)Lower in children than adults

Transiently increases with sneezing, coughing and valsalva manouvres

The overall volume of the cranial vault cannot change therefore an increase in the proportion of one component, or the presence of a pathologic component will result in displacement of structures, an increase in ICP or both.

….Who’s Doctrine is this??

The Monroe-Kellie Doctrine

Causes Too much Brain- Tumour, Haematoma, Oedema

Too much CSF- Choroid plexus papilloma, Arachnoid granulation

adhesions, Obstructive hydrocephalus Too much Blood- Obstruction of venous outflow (venous sinus thrombosis, jugular vein compression, neck surgery)

Consequences of Raised ICP

1. Cerebral blood flow-CBF = (CAP – JVP) / CVR-CPP = MAP - ICP

2. Brainstem compression

3. Both

What was happening to Jimmy?

HeadacheVomitingDepressed ConsciousnessFixed and dilated pupilsA triad of Bradycardia, Hypertension and respiratory depression….Also known as who’s triad?

Cushing’s Triad

Papilloedema

Little Timmy (Jimmy’s Brother)

20 year old male presents to ED post footy tackle with severe headstrike associated wth loss of consciousness 1 minute.

The next intern attended SSSM talks…

• D anger• R esponse (GCS)• S end for help (!!!!!!!)• A irway• B reathing • C irculation• D

ont(EverForgetGlucose)

• I Who am I

• S Whats happened

• B What’s happening

• A What I think

• R What I need

Eyes

4: Spontaneous eye opening3: Eye opening in response to speech2: Eye opening in response to pain1: No eye opening

Voice

5: Oriented4: Confused conversation3: Inappropriate speech2: Incomprehensible speech1: None

Motor

6: Obeying commands5: Localising response to pain4: Withdraws to pain3: Flexor response to pain2: Extensor posturing to pain1: No response to pain

Glascow Coma Scale

How do we know there’s raised raised ICP?ICU!

Monitoring of ICP is integral to treatmentMonitor ICP and BP to determine CPPMany Types of monitors

Indications for ICP monitoring

1. History2. Clinical findings3. Imaging

CT

TreatmentFIX THE CAUSE! REMOVE THE BLOOD CLOT RESECT THE TUMOUR SHUNT THE CSF TREAT THE METABOLIC DISORDER

Generally..Apropriate resuscitation (ABC)A – GCS <8, intubate (carefully)B – Give O2C – Ensure good end organ perfusion

....and treat the raised ICP!

Specifically.. Sedation

Elevate the head Hyperventilation

Mannitol Removal of CSF

Decompressive craniectomy

Sedation- Reduce metabolic demand- Reduce venous congestion- Reduce sympathetic response of hypertension and

tachycardia

PositionElevate head to maximise venous outflow (as long as cerebral perfusion pressure remains appropriate)Minimise stimuli that can induce Valsalva responses (eg endotracheal suctioning)

MannitolReduces brain volume by drawing free water our of the tissue and into the circulationQuick acting and Effects short livedProblems – Can lower BP and therefore CPP

Mechanical Hyperventilation

Lowering PaCO2 to 26 to 30 mmHg has been shown to rapidly reduce ICP through vasoconstriction and a decrease in the volume of intracranial blood.Effects short lived. Used as an urgent intervention, not on a chronic basis.May cause critical decrease in local cerebral perfusion (minimise use in TBI or actue stroke)

Removal of CSFVentriculostomy to remove CSF

http://www.uptodate.com/contents/image?imageKey=NEURO%2F56391&topicKey=NEURO%2F1659&rank=1%7E150&source=see_link&search=icp&utdPopup=true

Decompressive craniectomy

Circumvents Monroe-Kellie doctrineLowers ICP by 70%Improves brain tissue oxygenation

SummaryManagement requires

- Recognition- Monitoring- Therapy aimed at reducing ICP and treating the

underlying cause

Neurosurgical Pop Quiz‘Wacky, Wet and Wobbly’ is a good way to remember the symptoms ofA. Someone with a weak bladder who’s had too many beersB. An overweight delirious patient coming out of a poolC. Normal Pressure Hydrocephalus

Neurosurgical Pop QuizWhich surgeon is known as ‘the father’ of modern neurosurgery?

Harvey Cushing

Questions?