Increased Intracranial Pressure: A Guide For Nurses

What Is Increased Intracranial Pressure?

Increased intracranial pressure (ICP) can occur as a sign of a brain tumour, as a consequence of infection or maybe even as a subarachnoid haemorrhage from a fall (MedlinePlus 2019).

The skull is filled with brain matter, intravascular blood and cerebrospinal fluid (CSF). A process of auto-regulation allows these components to adjust to each other, which maintains a level ICP. When any of these volumes stop being regulated, pressure builds inside of the skull, resulting in increased ICP (Pinto, Tadi & Adeyinka 2019).

What Causes Increased ICP?

There are many potential causes of a raised ICP, including:

• Tumours;
• Haemorrhage;
• Oedema;
• Increases in cerebrospinal fluid (CSF);
• Aneurysm;
• Head injuries;
• Infections such as encephalitis or meningitis;
• Hydrocephalus;
• Hypertension;
• Stroke; and
• Epilepsy and seizures.

(John Hopkins Medicine 2016)

Signs and Symptoms

Consideration must be given to determine if the symptoms a patient is displaying can be attributed to another condition such as a stroke, or if they are a consequence of increased ICP.

The signs of increased ICP include:

• Headache;
• Vomiting;
• Restlessness and irritability;
• Increased blood pressure;
• Decreased mental abilities;
• Confusion about time, location and people as the pressure worsens;
• Double vision;
• Pupils that don’t respond to changes in light;
• Shallow breathing;
• Seizures;
• Decreased level of consciousness; and
• Coma.

(Carey 2018)

Cushing’s Triad

Cushing’s triad is seen when increased ICP decreases the cerebral blood flow significantly. A response is triggered that increases arterial pressure in order to overcome the increased ICP (Dinallo & Waseem 2020).

The signs of Cushing’s triad are:

• Hypertension and widening pulse pressure (the difference between the systolic and diastolic BP)
• Bradycardia
• Bradypnoea

(Dinallo & Waseem 2020)

At this point, if treatment does not occur to stabilise the ICP, herniation of the brain stem and occlusion of the cerebral blood flow can occur with dire consequences (Dinallo & Waseem 2020).

Management of Increased ICP

A compensatory mechanism does exist in the event of a slow compression of the brain. This includes adjustments such as veins compressing, CSF volume reducing and cerebral blood flow decreasing. However, these compensatory mechanisms only help for a certain amount of time (Farrell & Dempsey 2013).

There are several modes of treatment which aim to reverse the causes of the increased ICP:

Surgery such as a craniotomy is advised as soon as possible on people who are significantly neurologically compromised as it results in rapid decompression of the brain (Rangel-Castilla 2016).

Hyperventilation can be used, however, the findings for this mode of treatment are mixed and some studies have shown that patients who were hyperventilated had worse outcomes than those who were not (Rangel-Castilla 2016).

Mannitol can also be used and works through osmotic diuresis - that is, it draws oedema out of the cerebral tissues to decrease ICP. It also improves blood flow and can be used in patients with severe traumatic brain injuries. However, it needs to be monitored carefully (Rangel-Castilla 2016).

Nursing Management Of An Increased ICP

By closely monitoring patients who may be at risk of raised ICP, we can detect any changes promptly and therefore improve patient outcomes with early treatment interventions.

The nurse must monitor and report any early signs and symptoms of increasing ICP, which can be done by regularly attending to neurological observations on the patient. These signs include:

• Disorientation, restlessness, mental confusion and purposeless movements;
• Pupillary changes and impaired extraocular movements;
• Weakness in one extremity or hemiplegia; and
• Headache, constant in nature, increasing in intensity and aggravated by movement or straining.

(Farrell & Dempsey 2013)

If the patient’s condition progresses, the symptoms may worsen to:

• Deterioration in level of consciousness;
• Cushing’s triad;
• Altered respiratory patterns including Cheyne-Stokes breathing;
• Vomiting;
• Hemiplegia; and
• Loss of brain stem reflexes (pupillary, corneal, gag and swallowing reflexes).

(Farrell & Dempsey 2013)

If a patient is suspected of having an increased ICP, methods to reduce the pressure from increasing further include elevating the patient’s head to 30 degrees, keeping their neck in a neutral position, avoiding overhydration, maintaining normal body temperature and maintaining normal oxygen and carbon dioxide levels (Sippel 2011).

Increased ICP can be managed in many ways, including through medical and surgical interventions. Nurses need to ensure they are assessing and monitoring patients for any potential changes to ICP and reporting these changes promptly in order for early interventions to be implemented and patient outcomes to be improved.

References

• Carey, E 2018, ‘Increased Intracranial Pressure’, Healthline, viewed 7 September 2020, https://www.healthline.com/health/increased-intracranial-pressure
• Dinallo, S & Waseem, M 2020, ‘Cushing Reflex’, StatPearls, viewed 7 September 2020, https://www.ncbi.nlm.nih.gov/books/NBK549801/
• Farrell, M & Dempsey J (eds) 2013, Smeltzer & Bare’s Textbook of Medical-Surgical Nursing, 3rd edn, Lippincott, Williams & Wilkins, Broadway.
• John Hopkins Medicine 2016, Increased Intracranial Pressure (ICP) Headache, viewed 7 September 2020, https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/increased-intracranial-pressure-icp-headache
• MedlinePlus 2019, Increased Intracranial Pressure, MedlinePlus, viewed 7 September 2020, https://medlineplus.gov/ency/article/000793.htm
• Pinto, V L, Tadi, P & Adeyinka, A 2019, ‘Increased Intracranial Pressure’, StatPearls, viewed 7 September 2020, https://www.ncbi.nlm.nih.gov/books/NBK482119/
• Rangel-Castilla, L 2016, ‘Closed Head Injury Treatment and Management’, Medscape, viewed 7 September 2020, https://emedicine.medscape.com/article/251834-treatment
• Sippel, R 2011, ‘Intracranial Pressure and the Cushing Reflex’, EMSWorld, viewed 7 September 2020, https://www.emsworld.com/article/10453662/ems-recap-intracranial-pressure-and-cushing-reflex