Transcript Management of raised ICP - Surgical Students Society of

Management of Raised
ICP
Jon-Paul Chamoun
Case study
Little Jimmy
24 year old male presents to ED post footy tackle with severe
headstrike associated wth loss of consciousness 1 minute.
-
GCS 14 at the scene
-
Sore head
-On examination
HR 85 reg. BP 130/80 RR 22 36.8
CVS, Abdo, Resp NAD
Neuro: PEARL UL + LL Normal Tone Power Reflexes Sensation and
Coordination
Tea Break!
Beep Beep
‘Hi Dr, please review little Jimmy. Drowsy ++’
Crap, I missed the SSSM Neurosurg topics!
Little Jimmy..
Now
HR 40 BP 180/90 RR 8 36.8
Drowsy+++
Eyes crossed
Pupils dilated…
PANIC = Neurons not firing
A bad referral leads to…
RIP Little Jimmy
The drainage
Physiology
Inside the rigid Vault (~ 1500mls)
- Brain (80%)
- Blood (10%)
- CSF (10%)
Intracranial Pressure
Normal : <15mmHg (adults)
Lower in children than adults
Transiently increases with sneezing, coughing and valsalva
manouvres
The overall volume of the cranial vault cannot change
therefore an increase in the proportion of one component, or
the presence of a pathologic component will result in
displacement of structures, an increase in ICP or both.
….Who’s Doctrine is this??
The Monroe-Kellie Doctrine
Causes
 Too much Brain
- Tumour, Haematoma, Oedema
 Too much CSF
- Choroid plexus papilloma, Arachnoid granulation adhesions,
Obstructive hydrocephalus
 Too much Blood
- Obstruction of venous outflow (venous sinus thrombosis,
jugular vein compression, neck surgery)
Consequences of Raised ICP
1. Cerebral blood flow
-CBF = (CAP – JVP) / CVR
-CPP = MAP - ICP
2. Brainstem compression
3. Both
What was happening to Jimmy?
Headache
Vomiting
Depressed Consciousness
Fixed and dilated pupils
A triad of Bradycardia, Hypertension and respiratory
depression….Also known as who’s triad?
Cushing’s Triad
Papilloedema
Little Timmy (Jimmy’s Brother)
20 year old male presents to ED post footy tackle with severe
headstrike associated wth loss of consciousness 1 minute.
The next intern attended SSSM
talks…
• D anger
• I
Who am I
• R esponse (GCS)
• S
Whats happened
• S end for help (!!!!!!!)
• B
What’s happening
• A
What I think
• R
What I need
• A irway
• B reathing
• C irculation
• D ont(EverForgetGlucose)
Glascow Coma Scale
Eyes
Voice
Motor
4: Spontaneous eye opening
3: Eye opening in response
to speech
2: Eye opening in response
to pain
1: No eye opening
5: Oriented
4: Confused
conversation
3: Inappropriate
speech
2: Incomprehensible
speech
1: None
6: Obeying commands
5: Localising response
to pain
4: Withdraws to pain
3: Flexor response to
pain
2: Extensor posturing
to pain
1: No response to pain
How do we know there’s raised
raised ICP?ICU!
Monitoring of ICP is integral to treatment
Monitor ICP and BP to determine CPP
Many Types of monitors
Indications for ICP monitoring
1. History
2. Clinical findings
3. Imaging
CT
Treatment
FIX THE CAUSE!
 REMOVE THE BLOOD CLOT
 RESECT THE TUMOUR
 SHUNT THE CSF
 TREAT THE METABOLIC DISORDER
Generally..
Apropriate resuscitation (ABC)
A – GCS <8, intubate (carefully)
B – Give O2
C – Ensure good end organ perfusion
....and treat the raised ICP!
Specifically..
 Sedation
 Elevate the head
 Hyperventilation
 Mannitol
 Removal of CSF
 Decompressive craniectomy
Sedation
- Reduce metabolic demand
- Reduce venous congestion
- Reduce sympathetic response of hypertension and
tachycardia
Position
Elevate head to maximise venous outflow (as long as cerebral
perfusion pressure remains appropriate)
Minimise stimuli that can induce Valsalva responses (eg
endotracheal suctioning)
Mannitol
Reduces brain volume by drawing free water our of the tissue
and into the circulation
Quick acting and Effects short lived
Problems – Can lower BP and therefore CPP
Mechanical Hyperventilation
Lowering PaCO2 to 26 to 30 mmHg has been shown to
rapidly reduce ICP through vasoconstriction and a decrease
in the volume of intracranial blood.
Effects short lived.
Used as an urgent intervention, not on a chronic basis.
May cause critical decrease in local cerebral perfusion
(minimise use in TBI or actue stroke)
Removal of CSF
Ventriculostomy to remove CSF
http://www.uptodate.com/contents/image?imageKey=NEURO%2F56391&topicKey=NEURO%2F1659&rank=1%7E150&source=see_link&search=i
cp&utdPopup=true
Decompressive craniectomy
Circumvents Monroe-Kellie doctrine
Lowers ICP by 70%
Improves brain tissue oxygenation
Summary
Management requires
- Recognition
- Monitoring
- Therapy aimed at reducing ICP and treating the underlying
cause
Neurosurgical Pop Quiz
‘Wacky, Wet and Wobbly’ is a good way to remember the
symptoms of
A. Someone with a weak bladder who’s had too many beers
B. An overweight delirious patient coming out of a pool
C. Normal Pressure Hydrocephalus
Neurosurgical Pop Quiz
Which surgeon is known as ‘the father’ of
modern neurosurgery?
Harvey Cushing
Questions?