Download - Management of Raised ICP
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Management of Raised ICP
Jon-Paul Chamoun
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Case studyLittle 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 examinationHR 85 reg. BP 130/80 RR 22 36.8CVS, Abdo, Resp NADNeuro: PEARL UL + LL Normal Tone Power Reflexes Sensation and Coordination
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Tea Break!Beep Beep
‘Hi Dr, please review little Jimmy. Drowsy ++’
Crap, I missed the SSSM Neurosurg topics!
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Little Jimmy..NowHR 40 BP 180/90 RR 8 36.8
Drowsy+++Eyes crossedPupils dilated…
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PANIC = Neurons not firing
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RIP Little Jimmy
A bad referral leads to…
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The drainage
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PhysiologyInside the rigid Vault (~ 1500mls)
- Brain (80%)- Blood (10%)- CSF (10%)
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Intracranial PressureNormal : <15mmHg (adults)Lower in children than adults
Transiently increases with sneezing, coughing and valsalva manouvres
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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??
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The Monroe-Kellie Doctrine
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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)
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Consequences of Raised ICP
1. Cerebral blood flow-CBF = (CAP – JVP) / CVR-CPP = MAP - ICP
2. Brainstem compression
3. Both
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What was happening to Jimmy?
HeadacheVomitingDepressed ConsciousnessFixed and dilated pupilsA triad of Bradycardia, Hypertension and respiratory depression….Also known as who’s triad?
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Cushing’s Triad
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Papilloedema
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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.
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The next intern attended SSSM talks…
• D anger• R esponse (GCS)• S end for help (!!!!!!!)• A irway• B reathing • C irculation• D
ont(EverForgetGlucose)
• I Who am I
• S Whats happened
• B What’s happening
• A What I think
• R What I need
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Eyes
4: Spontaneous eye opening3: Eye opening in response to speech2: Eye opening in response to pain1: No eye opening
Voice
5: Oriented4: Confused conversation3: Inappropriate speech2: Incomprehensible speech1: None
Motor
6: Obeying commands5: Localising response to pain4: Withdraws to pain3: Flexor response to pain2: Extensor posturing to pain1: No response to pain
Glascow Coma Scale
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How do we know there’s raised raised ICP?ICU!
Monitoring of ICP is integral to treatmentMonitor ICP and BP to determine CPPMany Types of monitors
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Indications for ICP monitoring
1. History2. Clinical findings3. Imaging
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CT
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TreatmentFIX THE CAUSE! REMOVE THE BLOOD CLOT RESECT THE TUMOUR SHUNT THE CSF TREAT THE METABOLIC DISORDER
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Generally..Apropriate resuscitation (ABC)A – GCS <8, intubate (carefully)B – Give O2C – Ensure good end organ perfusion
....and treat the raised ICP!
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Specifically.. Sedation
Elevate the head Hyperventilation
Mannitol Removal of CSF
Decompressive craniectomy
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Sedation- Reduce metabolic demand- Reduce venous congestion- Reduce sympathetic response of hypertension and
tachycardia
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PositionElevate head to maximise venous outflow (as long as cerebral perfusion pressure remains appropriate)Minimise stimuli that can induce Valsalva responses (eg endotracheal suctioning)
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MannitolReduces brain volume by drawing free water our of the tissue and into the circulationQuick acting and Effects short livedProblems – Can lower BP and therefore CPP
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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)
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Removal of CSFVentriculostomy to remove CSF
http://www.uptodate.com/contents/image?imageKey=NEURO%2F56391&topicKey=NEURO%2F1659&rank=1%7E150&source=see_link&search=icp&utdPopup=true
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Decompressive craniectomy
Circumvents Monroe-Kellie doctrineLowers ICP by 70%Improves brain tissue oxygenation
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SummaryManagement requires
- Recognition- Monitoring- Therapy aimed at reducing ICP and treating the
underlying cause
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Neurosurgical Pop Quiz‘Wacky, Wet and Wobbly’ is a good way to remember the symptoms ofA. Someone with a weak bladder who’s had too many beersB. An overweight delirious patient coming out of a poolC. Normal Pressure Hydrocephalus
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Neurosurgical Pop QuizWhich surgeon is known as ‘the father’ of modern neurosurgery?
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Harvey Cushing
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Questions?
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