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Intracranial Pressure
ALL NUMBERS GIVEN ARE ISH

The Good, Bad & Ugly

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Neurological Pathophysiology
Cerebral blood flow (CBF) interrupted by:
Structural changes or damage Circulatory changes Alterations in intracranial pressure (ICP)

Monroe-Kellie Doctrine
The cranial vault is a fixed space consisting of 3 compartments:
Parenchyma (neurons and neuroglial tissue) - 80% CSF - 10% Blood - 10%

Three structures in the intracranial space:


Brain tissue Blood Water

Therefore, expansion of one compartment results in a compensatory decrease in another in order to maintain ICP

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Intracranial Space
Brain tissue Mostly water, intracellular and extracellular Blood - Intracranial circulation of blood is about 1000 liters per day delivered at a pressure of 100 mmHg and at any given time time, the cranium contains 75 ml (ish) Major arteries in base of brain Arterial branches, arterioles, capillaries, venules, veins within brain substance Cortical veins and dural sinuses

Intracranial Space
Water in:
Ventricles of brain Cerebrospinal fluid
Is constantly secreted, and after circulating, absorbed at an equal rate CSF circulation is slow (500 to 700 ml/day) At a given time the cranium contains 75 ml of CSF

Extracellular and intracellular fluid


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Cerebral Perfusion Pressure (CPP)

Important Concepts

Cerebral blood flow depends on cerebral perfusion pressure Cerebral blood flow controls oxygen and glucose delivery and waste removal It depends on the pressure gradient across brain
Cerebral perfusion pressure (CPP) and cerebral vascular bed resistance CPP determined by:
Mean arterial pressure (MAP): (Diastolic pressure + pulse pressure) minus intracranial pressure

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Cerebral Perfusion Pressure


Calculate CPP
Subtract ICP from MAP

The Bottom Line


< 50 mm Hg - Mild cerebral ischemia < 40 mm Hg - Cerebral blood flow down 25% < 30 mm Hg - Irreversible cerebral ischemia If MAP = ICP there is no gradient
Hence, there is no blood flow to the brain and brain death in imminent (seizure coma death)
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Example:
Patient has an ICP of 80 and a MAP of 113 113 MAP - 80 ICP = 33 CPP (BAD)

Best if > 70 mm Hg < 60 mm Hg = impaired blood flow to brain Can lead to seizure, coma and death
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Cerebral Blood Flow


As ICP approaches MAP:
Gradient for flow decreases Cerebral blood flow restricted

Autoregulation Of Cerebral Blood Flow


The main regulator of brain blood flow is pressure - dependent activation of smooth muscle in the arterioles of the brain. The more the arteriole is stretched, the more it contracts, and this lasts as long as the stretch occurs

When ICP increases, increases CPP decreases


As CPP decreases, cerebral vasodilation occurs Increases cerebral blood volume (increasing ICP) and further cerebral vasodilation
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More ICP (Bad) So So


Equals Less LOC (Also Bad)

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What Is Normal ICP?


0 to 15mm Hg in an adult (depends on where you look) Most text list it as < 15mm Hg

Factors Which Increase ICP


Hip flexion (decreases venous return) H d and Head d neck k position iti Changing level of height of bed (especially flat) External noxious stimuli Agitation Pain Coughing and valsalva maneuver Seizures

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What Can You Do?


Decrease external stimulation Ensure a quiet environment Pull slouching patients to the top of the b d bed Use cervical collar with decreased neck muscle tone Shut off bright lights Align head and neck
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Treatment
Ventilation: What is optimal PaO2 level?
Keep PaO2 between 90-120mmHg or SPO2

What is the optimal PaCO CO2


Old method Keep PaCO2 at 25 mmHg New method Keep PaCO2 range 30-35 mmHg

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Treatment
Analgesia and Sedation
Reduces movement Helps with ventilation Reduces perceived pain Limits responses to procedures such as suctioning

Of Course

A lot of different ones fentanyl, midazolam, propofol etc


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If you feel up to it, there is always surgery


g y by y numbers? Surgery

A Little Bit About ICP Monitoring

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ICP Monitoring - Indications


Glasgow coma score <8
Abnormal CT scan - 50-60% risk Normal CT Scan, Age > 40 or BP < 90mmHg or abnormal motor posturing - 50-60% risk Normal CT scan with no risk factors - 13% risk

Devices
Interventricular cannula (IVC) Epidural catheter Subdural / subarachnoid monitoring devices Fiber optic transducer tipped probe

Glasgow coma score 9 to 12


If paralytic and/or sedative medications are being used or abnormal CT scan - 10-20% will deteriorate to severe head injury

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Interventricular Cannula (IVC)


Most commonly used monitor Placed within the ventricle

IVC

Interventricular Cannula (IVC)


Advantages
Drain CSF to lower ICP Obtain CSF cultures Increased accuracy in ICP monitoring Accurate and reliable

Interventricular Cannula (IVC)


Transport considerations
System set-up Charting g ICP Drainage orders Movement Pressure changes with air transport

Disadvantages
Infection Injury to brain Clot formation Hemorrhage risk Collapsed ventricle Placement may be impossible

Abnormal Wave Forms


P2 > P1 Autoregulation gone and things are swirling the drain. A waves are next

Abnormal Wave Forms

Things Are Headed South

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Questions?

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