Trauma, stroke, hypertension, and infection are just some of the ailments that can cause an increase in intracranial presusure. Signs and symptoms such as altered LOC, nausea and vomiting, seizures, headaches, focal defecits, and anisocoria are just some of the clues that our patients ICP is rising. Now what we do for them in the emergency department is what we are going to discuss here.
- How do we recognize a possible increase in ICP?
- What are some causes of this increase?
- What do we do for them in the emergency department?
- Early signs vs Late Signs
- Behavior Changes
- Altered LOC
- Dilated, Nonreactive Pupils
- Cushings Triad
- Intercanial Hemorrhage
- Ruptured Aneurysm
- Cerebral Edema
- Serial Neuro assessment
- Glasgow Coma Scale
- Verbal Response 1-4
- Eye Opening 1-5
- Motor Response 1-6
- Glasgow Coma Scale
- Pupillary Assessment
- Reflex assessment
- Decorticate Posturing
- Decerebrate Posturing
- Reduce Intracranial Pressure
- Sedation and analgesia
- Osmotic Diuretic
- Decrease Stimulation
- Take off that C-Collar
- Insertion of ICP monitor
- Possibe ventriculostomy in ED
- Prepare for emergent surgical decompression
- Intracranial regulation
- Signs of a change in mental status
- Stress importance of not ignoring warning signs. If you dont know….go!
Welcome to another lesson in our Emergency Management series. Today we are going to discuss increased intracranial pressure. Specifically how to identify it in the ED and what to do about it.
Just because we may not have an intracranial monitor, does not mean we cant spot an increase in intracranial pressure. Altered LOC, nausea and vomiting, seizures, headaches, focal defecits, and anisocoria are just some of the signs and symptoms that can indicate an increase in ICP. It’s vital to know the steps to take when we witness these changes.
So what will tell us that our patient may have an increasing intracranial pressure, or ICP. There are early signs and late signs (and trust me, you don’t want to see the late signs.) Some of the early signs are a headache, which may be minor or severe. They may have some nausea and vomiting. They can suffer amnesia and this can be as simple as not remembering there injury or as serious as forgetting their own name. The may also start having behavior changes like some impaired judgement, increased restlessness and on the flip side, increased drowsiness. All of this can lead to an alteration in level of consciousness.
Late signs can be dilated, nonreactive pupils (It starts as unilateral and progresses). They will become unresponsive to verbal or painful stimuli. They might begin to have some abnormal posturing and muscular rigidity, and they can begin to show the Cushing’s response which is a combination of a widening pulse pressure, bradycardia and decreased respirations. If you see this combination of symptoms…this is a very, very bad thing. It is usually a sign that their brain is herniating. I think it goes without saying that this is a true emergency.
Increased ICP comes from the insult to the brain. This can be from a number of causes. The most common is head trauma.
It can also be caused from a hemorrhage that can be the result of a stroke, or a ruptured aneurysm. There can also be non traumatic causes such as hydrocephalus, or tumors or general cerebral edema. Basically anything that causes the space in the skull to decrease is going to cause an increase in ICP. Blood, CSF or swelling of the brain itself can all lead to a very very bad day for our patient.
If you guys want to learn more about intracranial pressure, you know like what’s normal, all the ways it can increase or decrease and things like the Monroe-Kelli Doctrine, please check out the Neuro course under our med surg units here on NRSNG.com.
So what do we do in the ED. Well first, and often, we have to assess. Our first and most common neuro assessment is the Glascow Coma Scale or GCS. This is a measurement of a patient’s verbal response, eye opening and motor response. The scale goes from 3-15 with 15 being perfect and 3 being….well not much at all. I have said it before and it bears repeating, technically your computer screen has a GCS of 3, so if your patient also does…you can imagine that it is not a good thing.
We will continue to perform pupillary assessments being on the lookout for anisocoria, which is a fancy medical term for unequal pupils like the spooky guy right here.
We also want to watch the patient’s reflexes and be aware of posturing. We look for decorticate posturing, where the forearms are pulled towards the center of the chest, or decerebrate, in which the arms are straight at the sides and the wrists and hands are facing out. Decerebrate is usually a very late sign of ICP and can be a sign or brain herniation.
Lets treat our guy. If the ICP is being cause by restlessness, anxiety, or pain,we would need to relax our patient and get them out of pain. Cue the meds. Something for sedation and something for pain should be given. On top of that, you might want to give an osmotic diuretic like Mannitol to decrease the ICP.
If the C-Spine has been cleared, please, for the love of god, get that C-collar off. If you wonder how comfortable that thing is, go put one on and see how your patient feels. Also, medically, the C-collar can actually reduce venous outflow due to the pressure on the jugulars. Once we know the C-spine is good, we can elevate the head of the bed about 30 degrees. Don’t go too high, or too low and it can actually cause more pressure. Too low due to increased bloow flow to the head, and too high due to increase in abdominal pressure preventing venous return.
We want to decrease stimulation as much as possible. I know that seems crazy in the ED environment, and in the acute lifesaving situation, it is. But once the patient is stabilized, we want to try to move them to a quiet, dimly lit, monitored area where we can provide thorough care with the minimum of irritation to the patient.
If their GCS is 8 or less and they have an abnormal CT scan, neuro might elect to get more involved. In the ED they can place an internal ICP monitor or perform a ventriculostomy (you know, drilling a hole in the skull) and inserting an extraventricular drain, or EVD, to drain out the building fluid.
If all this is not enough, we will need to get them to the OR and perform an emergency craniotomy.
So we need to keep an eye on our patients cognition and we do that by performing our serial neuro assessments.
With intracranial pressure, it’s all about proper regulation, whether that be through simple means or advanced techniques like medications or surgical procedures.
And we need to know what is important. Do we intubate first, or position them first. To we give mannitol or morphine first. Much like many of our ED cases, prioritization is vital to their proper care.
Key points time:
Know the signs of increasing ICP. Whats early and what’s late.
There are lots of possible causes. That thorough history is going to help your diagnosis and treatment.
Perform those neuro assessments and document that GCS well
Whether we are doing something non invasive or invasive, we have to do something to help our patient.
And continue to monitor these guys. If not, they can crash very quickly and we need to pick up on the subtle cues that will alert us of the downward spiral.
OK guys, so that all about increasing ICP for today. Feel free to check out some of our other emergency medicine lessons through out NRSNG.com and as always…