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Management of Raised ICP

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

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Management of Raised ICP

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  1. Management of Raised ICP Jon-Paul Chamoun

  2. 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 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

  3. Tea Break! • Beep Beep ‘Hi Dr, please review little Jimmy. Drowsy ++’ Crap, I missed the SSSM Neurosurg topics!

  4. Little Jimmy.. Now HR 40 BP 180/90 RR 8 36.8 • Drowsy+++ • Eyes crossed • Pupils dilated…

  5. PANIC = Neurons not firing

  6. RIP Little Jimmy A bad referral leads to…

  7. The drainage

  8. Physiology • Inside the rigid Vault (~ 1500mls) • Brain (80%) • Blood (10%) • CSF (10%)

  9. Intracranial Pressure • Normal : <15mmHg (adults) • Lower in children than adults • Transiently increases with sneezing, coughing and valsalvamanouvres

  10. 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??

  11. The Monroe-Kellie Doctrine

  12. 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)

  13. Consequences of Raised ICP • 1. Cerebral blood flow -CBF = (CAP – JVP) / CVR -CPP = MAP - ICP • 2. Brainstem compression • 3. Both

  14. 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?

  15. Cushing’s Triad

  16. Papilloedema

  17. 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.

  18. The next intern attended SSSM talks… • I Who am I • S Whats happened • B What’s happening • A What I think • R What I need • D anger • R esponse (GCS) • S end for help (!!!!!!!) • A irway • B reathing • C irculation • D ont(EverForgetGlucose)

  19. Glascow Coma Scale Eyes 4: Spontaneous eye opening 3: Eye opening in response to speech 2: Eye opening in response to pain 1: No eye opening Voice 5: Oriented 4: Confused conversation 3: Inappropriate speech 2: Incomprehensible speech 1: None Motor 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

  20. 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

  21. Indications for ICP monitoring • History • Clinical findings • Imaging

  22. CT

  23. Treatment FIX THE CAUSE! • REMOVE THE BLOOD CLOT • RESECT THE TUMOUR • SHUNT THE CSF • TREAT THE METABOLIC DISORDER

  24. Generally.. • Apropriate resuscitation (ABC) • A – GCS <8, intubate (carefully) • B – Give O2 • C – Ensure good end organ perfusion ....and treat the raised ICP!

  25. Specifically.. • Sedation • Elevate the head • Hyperventilation • Mannitol • Removal of CSF • Decompressivecraniectomy

  26. Sedation • Reduce metabolic demand • Reduce venous congestion • Reduce sympathetic response of hypertension and tachycardia

  27. 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)

  28. 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

  29. 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)

  30. 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=icp&utdPopup=true

  31. Decompressivecraniectomy • Circumvents Monroe-Kellie doctrine • Lowers ICP by 70% • Improves brain tissue oxygenation

  32. Summary • Management requires • Recognition • Monitoring • Therapy aimed at reducing ICP and treating the underlying cause

  33. 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

  34. Neurosurgical Pop Quiz • Which surgeon is known as ‘the father’ of modern neurosurgery?

  35. Harvey Cushing

  36. Questions?

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