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Understanding Increased Intracranial Pressure

May 24, 2025

Increased Intracranial Pressure (ICP)

Definition

  • Increased ICP is when there is an increase in pressure inside the skull and around the brain.
  • Normal ICP: 5 to 15 mmHg.
  • ICP > 20 mmHg is abnormal and requires reporting.

Causes

  • Tumors
  • Head trauma (e.g., injury or stroke)
  • Infections (e.g., meningitis, encephalitis)

Signs and Symptoms

Decreased Level of Consciousness (LOC)

  • Lethargy, confusion, restlessness, agitation.
  • Measured using the Glasgow Coma Scale (GCS).

Glasgow Coma Scale (GCS)

Behavior: Eye Opening

  • Score 4: Opens eyes spontaneously.
  • Score 3: Opens eyes to voice.
  • Score 2: Opens eyes to pain.
  • Score 1: No eye opening.

Best Verbal Response

  • Score 5: Correct answers to orientation questions.
  • Score 4: Confused.
  • Score 3: Inappropriate words.
  • Score 2: Incomprehensible sounds.
  • Score 1: No verbal response.

Best Motor Response

  • Score 6: Obeys commands.
  • Score 5: Localizes to pain.
  • Score 4: Withdraws from pain.
  • Score 3: Flexes abnormally (decorticate).
  • Score 2: Extends abnormally (decerebrate).
  • Score 1: No motor response.

Other Symptoms

  • Headache, vomiting.
  • Seizures.
  • Eye issues: Ipsilateral dilation, sluggish pupils, ptosis, blurred vision, diplopia, papilledema.
  • Motor and reflex issues: Hemiplegia, positive Babinski's sign.
  • Vital sign changes: Increased temperature, low pulse, high blood pressure, respiratory changes (Cheyne-Stokes respirations).
  • Cushing's triad: Opposite of shock (high BP, low pulse, low RR).
  • Herniation risk: Fixed dilated pupils, unresponsiveness.

Diagnostic Tools

  • CT scans (quick and effective for immediate intervention).
  • MRI (more specific but slower).
  • Avoid lumbar puncture (risk of herniation).

Monitoring

  • ICP monitoring with ventriculostomy (EVD).
  • Score <8 on GCS with abnormal CT/MRI requires monitoring.
  • Risk of infection: Monitor temperature.

Nursing Interventions

  • Position: Elevate head of bed to 30 degrees, maintain midline position.
  • Avoid factors increasing ICP: Fever, CO2 levels, intra-abdominal pressure, and environmental stimuli.
  • PRN suctioning, pre-oxygenate before suctioning.

Medical Interventions

Medications

  • Mannitol: Osmotic diuretic to reduce brain edema.
  • Hypertonic Saline: Similar effect as mannitol.
  • Steroids (Dexamethasone): Reduce inflammation (avoid in head injuries).
  • Add H2 antagonists or PPIs to prevent GI bleed.
  • Anti-seizure drugs: Phenytoin, Phenobarbital (monitor for respiratory depression).
  • Acetaminophen: Reduce fever.
  • Sedatives: Propofol, fentanyl, benzodiazepines (e.g., midazolam).
  • Neuromuscular blockers: Cisatracurium.

Monitoring

  • Effectiveness measured by decreased ICP and improved LOC.

Important Note: Clinical management requires close monitoring and intervention to prevent severe complications such as brain herniation and potential death.

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