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Intracranial pressure measurement
1. Presented To: Presented By:
Mrs. Vinay Kumari Amandeep Kaur
Associate Professor Msc. (N) 2nd year
MMCON 1915703
2. The skull is a rigid structure.
It contains:
Brain
Blood
Cerebro spinal fluid (CSF)
Any increase of theses contents and/or the addition
of any mass will lead to increase in the pressure
(the Monroe-Kellie doctrine).
4. COMPENSATORY MECHANISMS FOR
EXPANDING MASSES:
Immediate
Decrease in CSF volume by movement of fluid to
the lumbar area.
Decrease in the blood volume by squeezing blood
out of sinuses
Delayed
Decrease in the extra-cellular fluid.
5. CEREBROSPINAL FLUID
Secreted at the rate of 500 mls per day
Secreted by the choroid plexus in the lateral ventricles
Flows through the ventricular system
Exits to the subarachnoid space through the foramina of
Magendie and Luschka
Absorbed into the venous system via the arachnoid
granulations
Any obstruction to the flow will lead to
HYDROCEPHALUS and increased pressure.
6. BRAIN OEDEMA
An excess of brain water may occur:
Around lesions within the brain:
Tumor
Abscess
In relation to traumatic damage
In relation to ischemic brain insult
Leads to increase in the pressure.
Types of edema:
Vasogenic (extra cellular): tumors
Cytotoxic (intra cellular): metabolic states
Interstitial (extra cellular): increased IVP
9. Autoregulation of cerebral blood flow
Regulation of CSF
Regulation with help of metabolic changes
10. Pathologic States that increase the volume of
one component necessitate decrease in the
volume of another to maintain normal Intra-
Cranial Pressure.
Brain
CSF
Cerebral blood volume
11. Glasgow Coma Scale (GCS ) < 8
Posturing (extension, flexion)
Bilateral or unilateral pupil dilation (except with
Epidural Hematomas)
CT Scan results showing edema and/or mid-line
shift
Physical assessment /neurological assessment
findings which indicate a need for monitoring
13. Intracranial pressure (ICP) is the pressure
inside the skull and thus in the brain tissue and
cerebrospinal fluid (CSF)
Normal range 5 – 15 mm Hg
14. Normally 0-140 mm CSF (0-10 mm Hg)
There are normal regular waves due to pulse and
respiration
With increased pressure “pressure waves” appear
With continued rise of ICP the PP falls
When PP falls CBF is reduced
Electrical cortical activity fails if CBF is 20ml/100gm/min
When intracranial pressure reaches mean arterial pressure
circulation to the brain stops.
15.
16.
17. Internal herniation:- Temporal lobe is pushed
down though Tentorium in cisura
External herniation:- Cerebellar tonsills/
peduncle herniate through foramen magnum →
Compressing over IV ventricle → ↓CPP →
Death == “CONING”
18. Effective pressure that allows the perfusion of
blood through the brain
CPP = MAP – ICP
Mean arterial pressure (MAP) = DP+ (SP-DP)
DP + PP/3 3
(ICP CVP)
CPP MAP – CVP
19. Normal CBF 45 – 50 ml / 100 gm / min
Range 20 ml / kg / min to 70 ml / kg / min
CBF Highest Frontal region
CBF Medium Parietal region
CBF Lowest Temporal area
20. Cerebral Autoregulation
Normal range MAP 50 – 150 mm Hg
If Head injured ~~ Failure of autoregulation
CBF = < 20ml / kg /min.
Adverse effect on ICP
21. Increased ICP is defined as a sustained
elevation in pressure above 20mm of Hg
ICP <15 mm of Hg – Intracranial hypertension
• Acute
• Chronic
Levels ICP in mmHg
Normal
Mild
Moderate
Severe
Very Severe
5 – 15
16 - 20
21 - 30
31 - 40
41 & Above
22. During slow increase in volume in a continuous mode,
the ICP rises to a plateau level at which the increase
level of CSF absorption keeps pace with the increase in
volume.
Intermittent expansion causes only a transient rise in
ICP at first. When sufficient CSF has been absorbed to
accommodate the volume the ICP returns to normal.
23. Expansion to a critical volume does however cause
persistent rise in ICP which thereafter increases
logarithmically with increasing volume ( volume -
pressure relationship).
THE VOLUME PRESSURE RELATIOSHIP
24. The ICP finally rises to the level of arterial pressure
which it self begins to increase, accompanied by
bradycardia or other disturbances of heart rhythm
(Cushing response). This is accompanied by dilatation
of small pial arteries and some slowing of venous flow
which is followed by pulsatile venous flow.
29. Findings Score
1) Eye opening
Spontaneous
To voice
To Pain
None
4
3
2
1
2) Best verbal response
Oriented
Confused speech
Inappropriate words
Incomprehensible sounds
None
5
4
3
2
1
3)Best motor response
Obeys Commands
Localizes pain
Withdraws
Abnormal flexion
Extension
None
6
5
4
3
2
1
Prognostic value as per GCS
Score Percentage
GCS 3/ less
GCS 3 – 5
GCS 6 – 8
100
60 – 84
36 – 46
30.
31.
32.
33. Meaning : The monitoring of intracranial pressure is
used in treating severe traumatic brain injury patients.
This process is called intracranial pressure monitoring.
All current clinical available measurement methods are
invasive and use various transducer systems.
Ventricular system
Sub-arachnoid space
Epidural space
Brain parenchyma
35. 1. External Ventricular Drainage (EVD). Invasive
monitoring using the EVD technique, where a catheter
is placed into one of the ventricles through a burr hole,
is considered the gold of ICP monitoring. In addition to
measuring ICP, this technique can also be used for
drainage of CSF and administering of medicine intra-
thecally, for example, antibiotic administration in cases
of ventriculitis, possibly resulting from EVD
placement itself.
36.
37.
38. 2. Micro-transducer ICP Monitoring Devices.
This group of invasive ICP monitoring devices can
be divided into fiber optic devices, strain gauge
devices, and pneumatic sensors.
39.
40. The idea of a noninvasive method of measuring
ICP is captivating, as complications seen in
relation to the invasive methods of ICP measuring,
that is, hemorrhage and infection, are avoidable.
Different techniues have been proposed.
1. Transcranial Doppler Ultrasonography (TCD).
The TCD technique applies ultrasound to initially
measure the blood flow velocity in the middle
cerebral artery. The difference between systolic
and diastolic flow velocity, divided by the mean
flow velocity, is called the pulsatility index (PI).
41. 2. Tympanic Membrane Displacement (TMD). The
technique takes advantage of the communication of the
CSF and the perilymph via the perilymphatic duct.
Stimulation of the stapedial reflex causes a movement
of the tympanic membrane, which is shown to correlate
to ICP.
3. Fundoscopy and Papilledema. Papilledema, or optic
disc swelling, due to raised ICP can be visualized by
fundoscopy and graded by the Fris´en Scale into 5
categories depending on signs of disturbed axoplasmic
transport.
59. ASSESSMENT
History
Present Illness
Obtain Subjective Data
Neurologic examination
Mental Status
LOC
Cranial Nerve Function
Cerebral Function (balance and coordination)
Reflexes
Motor and Sensory Function
Abnormal Respiratory Pattern
60. NURSING DIAGNOSIS
Ineffective airway clearance related to diminished
protective reflexes
Ineffective breathing patterns related to neurologic
dysfunction
Ineffective cerebral tissue perfusion related to the
effects of increased ICP
Deficient fluid volume related to fluid restriction
Risk for infection related to ICP monitoring system
61. PLANNING AND GOALS
Maintenance of patent airway
Normalization of respiration
Adequate cerebral tissue perfusion through
reduction in ICP
Restoration of fluid balance
Absence of infection
Absence of complication
62. NURSING INTERVENTION
Maintaining patent airway and adequate
ventilation
Monitor vital signs
Maintain fluid balance
Position client with head of the bed elevated 30 to
45 degrees and neck in neutral position
Maintain a quiet environment
Avoid use of restraints
Prevent straining at stool
Prevent excessive cough and vomiting
Prevent complication of immobility
Preventing infection
Administer medication as ordered
64. I.C.P. is an important parameter
Physiology
Pathology related to increased ICP
Monitoring of ICP
Interaction between ICP and anaesthetic agents
Anaesthesiologist as Peri-operative Physician
65. B.Mokri, “TheMonro-Kellie hypothesis: applications
in CSF volume depletion,” Neurology, vol. 56, no. 12,
pp. 1746–1748, 2001.
A. Monro, Observations on Structure and Functions of
the Nervous System, Creech and Johnson, Edinbourg,
UK, 1783.
G. Kellie, “Appearances observed in the dissection of
two individuals; death from cold and congestion of the
brain,” Transactions of the Medico-Chirurgical Society
of Edinburgh, vol. 1, article 84, 1824.
F.Magendie, “Recherches anatomique et physiologique
sur le liquide c´ephalo-rachidien ou c´erebro-spinal,”
Paris, France,1842.