Intracranial pressure NS Nurses class.pptx

lecture to nursing staffs

1. Intracranial Pressure Presenter: Bikram Shakya NOTICE CME Topic Presentation today VENUE: NEUROSURGERY OFFICE Time: 12:00 noon The CME would be Followed by LUNCH PACK

2. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Objectives Treatment options Surgical Approaches Understanding Intracranial Pressure Recognising clinical presentations Diagnostic approaches Treatment modalities Surgical approaches Interactive learning Outcomes / Summary Intracranial Pressure

3. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cranium Treatment options Surgical Approaches The cranium is an in expandable VAULT Summary Intracranial Pressure

4. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cranium Treatment options Surgical Approaches Summary

5. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Autoregulation Treatment options Surgical Approaches ~ process by which brain maintains its perfusion pressure over wide range of systemic pressures Highly dependent upon MAP (Normal MAP: 70 - 105 mm Hg) Patients with IICP: MAP 70 - 90 mm Hg OTHERWISE DECOMPENSATION can occur Prognosis and outcomes Intracranial Pressure

6. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Autoregulation Treatment options Surgical Approaches Summary Intracranial Pressure

7. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Intracranial pressure Treatment options Surgical Approaches ~ Pressure exerted by brain tissue, blood & CSF against inside of skull Increased Intracranial Pressure (IICP): Sustained pressure of 20 mm Hg or higher Normal Intracranial Pressure: 5 - 15 mm Hg [0 - 15 mm Hg] Summary Intracranial Pressure

8. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cerebral perfusion pressure (CPP) Treatment options Surgical Approaches ~ pressure required to perfuse brain Normal: 60 - 100 mm Hg Most important single factor in maintaining brain health Summary Intracranial Pressure

9. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cerebral perfusion pressure (CPP) Treatment options Surgical Approaches ~ pressure required to perfuse brain Normal: 60 - 100 mm Hg MAP - ICP = CPP Most important single factor in maintaining brain health Summary Intracranial Pressure

10. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cerebral perfusion pressure (CPP) Treatment options Surgical Approaches ~ pressure required to perfuse brain Normal: 60 - 100 mm Hg MAP - ICP = CPP Most important single factor in maintaining brain health Summary Intracranial Pressure

11. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cerebral perfusion pressure (CPP) Treatment options Surgical Approaches Normal: 60 - 100 mm Hg MAP - ICP = CPP MAP: 75 ICP: 22 CPP: 75 - 22 = 53 CPP: 75 - 10 = 65 MAP: 55 ICP: 5 CPP: 55 - 5 = 50 CPP: 75 - 5 = 70 Summary Intracranial Pressure

12. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Cerebral perfusion pressure (CPP) Treatment options Surgical Approaches Normal: 60 - 100 mm Hg MAP - ICP = CPP MAP: 75 ICP: 22 CPP: 75 - 22 = 53 CPP: 75 - 10 = 65 MAP: 55 ICP: 5 CPP: 55 - 5 = 50 CPP: 75 - 5 = 70 Summary Intracranial Pressure Cerebral Blood Flow (CBF): amount of blood (ml) passing through 100 gm of brain tissue

13. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Intracranial Pressure Treatment options Surgical Approaches Summary Intracranial Pressure Rigid cranial vault + 3 Non-compressible contents: Blood, Brain tissue, CSF If the VOLUME of one increases, then a reciprocal decrease in one or both of the others must occur

14. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Monroe-Kellie Doctrine Treatment options Surgical Approaches Summary Intracranial Pressure

15. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Monroe-Kellie Doctrine Treatment options Surgical Approaches Summary Intracranial Pressure

16. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Intracranial Pressure Treatment options Surgical Approaches Summary Intracranial Pressure Compliance: CSF? Displaced into subarachnoid space Blood? Vasodilation / constriction; displaced into venous sinuses Both Blood and CSF can only be displaced so much… Brain tissue? Herniation :- ( (moves from high pressure to low pressure area)

17. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Treatment options Surgical Approaches Summary Intracranial Pressure Intracranial Pressure

18. Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Causes of IICP Treatment options Surgical Approaches ~ increase in brain volume , cerebral blood volume or CSF BRAIN Cerebral oedema Infection; Meningitis, Encephalitis, Guillain Barre Syndrome, etc. Brain treatment; Radiation therapy Stroke (Ischemia) Brain Mass, tumour, abscess, contusions Summary Intracranial Pressure Aetiology

19. Etiology Clinical Features Diagnosis and Evaluation Causes of IICP Treatment options Surgical Approaches ~ increase in brain volume, cerebral blood volume or CSF BLOOD Intracranial Haemorrhage Closed head injury; Head Trauma, Skull fracture Stroke (Hemorrhagic) Increased blood flow HTN Vasodilation: Hypercapnea & Hypoxia (Mountain sickness) Increased oxygen demands: body triggers increase in CBF to augment Oxygen supply —> Fever, pain, physical activity, shivering, seizures Summary Intracranial Pressure

20. Etiology Clinical Features Diagnosis and Evaluation Causes of IICP Treatment options Surgical Approaches ~ increase in brain volume, cerebral blood volume or CSF BLOOD Obstruction of outflow (impaired venous return) Hyperflexion, hyperextension, rotation of neck, tight tracheostomy ties, tumour / abscess compressing venous return Increased intraabdominal or intrathracic pressure (pushes back against venous outflow Summary Intracranial Pressure

21. Etiology Clinical Features Diagnosis and Evaluation Causes of IICP Treatment options Surgical Approaches ~ increase in brain volume, cerebral blood volume or CSF CSF Hydrocephalus Blockage of CSF outflow CSF absorption Blockage Excess CSF production Summary Intracranial Pressure

22. Etiology Clinical Features Diagnosis and Evaluation IICP Treatment options Surgical Approaches Summary Intracranial Pressure

23. Etiology Clinical Features Diagnosis and Evaluation IICP Treatment options Surgical Approaches Summary Intracranial Pressure

24. Etiology Clinical Features Diagnosis and Evaluation IICP Treatment options Surgical Approaches Summary Intracranial Pressure Mid line shift; > 5 mm is considered significant

25. Clinical Features Diagnosis and Evaluation Clinical features Treatment options Surgical Approaches Headache, Vomiting, Altered sensorium, Cushing’s triad (HTN, Abnormal breathing, Bradycardia), Chyne Stokes Respiration, Pupil changes (constriction —> Dilatation), Decreased visual acuity, Papilledema (absent venous pulsation at disc) Summary Intracranial Pressure

26. Clinical Features Diagnosis and Evaluation Clinical features Treatment options Surgical Approaches Headache, Vomiting, Altered sensorium, Cushing’s triad (HTN, Abnormal breathing, Bradycardia), Chyne Stokes Respiration, Pupil changes (constriction —> Dilatation), Decreased visual acuity, Papilledema (absent venous pulsation at disc) Summary Intracranial Pressure

27. Clinical Features Diagnosis and Evaluation Clinical features Treatment options Surgical Approaches Headache, Vomiting, Altered sensorium, Cushing’s triad (HTN, Abnormal breathing, Bradycardia), Chyne Stokes Respiration, Pupil changes (constriction —> Dilatation), Decreased visual acuity, Papilledema (absent venous pulsation at disc) Summary Intracranial Pressure

28. Diagnosis and Evaluation Investigations Treatment options Surgical Approaches FBC, LFT, Glucose Serum Electrolytes Bleeding Profile Toxicology screening CXR CT / MRI Head LP (if safe, measure opening pressure) Summary

29. Management Treatment options Surgical Approaches PRIMARY MANAGEMENT ABC Approach HTN Correction (MAP > 90 mm Hg) Control Seizure Brief History and Examination Summary Intracranial Pressure

30. Clinical Features Diagnosis and Evaluation Secondary Management Treatment options Surgical Approaches Aim to make diagnosis Treat cause or exacerbating factors (Eg. Hyperglycaemia, Dyselectrolytemia, etc) Definitive treatment Summary Intracranial Pressure

31. Clinical Features Diagnosis and Evaluation Conservative Management Treatment options Surgical Approaches Tier I 1. Head tilt @ 30 - 45’ Increase CSF & Venous Drainage 2. Mild analgesics / sedation 3. Isoventilation (Vs Hyperventilation) 4. Isotherm Summary Intracranial Pressure

32. Clinical Features Diagnosis and Evaluation Conservative Management Treatment options Surgical Approaches Tier II 1. Osmotic diuresis 20% Mannitol 0.25 - 0.5 g / Kg IV over 10-20 mins Effect seen after ~ 20 mins, lasts 2-6 hours IV Hypertonic saline (3%, 7.5%, 23.4% NS) To keep S Osmolarity ~ 300 mosmol/Kg; not to exceed 310 Summary Intracranial Pressure

33. Clinical Features Diagnosis and Evaluation Management Treatment options Surgical Approaches Tier II 2. Corticosteroids Oedema surrounding Tumors Dexamethasone 8-10 mg stat, 4 mg / 6 hrs; IV / PO 3.Ventriculostomy 4. Hyperventilation 5. Ionodilators Summary Intracranial Pressure

34. Management Surgical Approaches Tier II Vetriculostomy Summary Summary

35. Management Surgical Approaches Tier II ICP Monitoring Summary Intracranial Pressure

36. Management Treatment options Surgical Approaches Tier III 1. High dose sedation to induce coma Barbiturates (DOC: Thiopentane sodium, Vecuronium) 2. Therapeutic Hypothermia 3. Craniectomy Summary Intracranial Pressure

37. Management Surgical Approaches Tier III 3. Craniectomy Summary Intracranial Pressure

38. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Treatment options Surgical Approaches Summary Understanding Intracranial Pressure Recognising clinical presentations Diagnostic approaches Treatment modalities Surgical approaches Interactive learning Summary Intracranial Pressure

39. Introduction Doctrine of Monroe Kellie Clinical Features Diagnosis and Evaluation Treatment options Surgical Approaches Summary Thank you Intracranial Pressure Neuro Nurse