T9: Intracranial Pressureand Brain Tumors Flashcards
coup-contrecoup injury
Dual impacting of the brain into the skull; coup injury occurs at the point of impact; contrecoup injury occurs on the opposite side of impact, as the brain rebounds.
what are the 3 essential components of the skull
1.Brain tissue
2.Blood
3.Cerebrospinal fluid (CSF)
factors that influence ICP
*Arterial pressure
*Venous pressure
*Intraabdominal and intrathoracic pressure-Valsalva-bearing down
*Posture
*Temperature (cold vasoconstricts and drops ICP, fever dialtes and can take up space in the head and cause seizures)
Blood gases (CO2 levels)
what does oxygen do to brain vessels
dilates
what does CO2 do to brain vessels
constricts
what are normal compensatory adaptation that change volume in the brain
*CSF
*intracranial blood volume
*tissue brain volume
if volume int he brain increases, then..
ICP rises and decompensation occurs resulting in compression and ischemia
how much of the body’s oxygen does the brain use
20%
how much of the body’s glucose does the brain use
25%
the brain does not store
glucose; this is why we need sugar to function
what is the mean arterial pressure for the brain
70-150mmHg
cerebral perfusion pressure (CPP)
is the pressure needed to ensure blood flow to the brain (what is needed to perfuse the brain tissue)
calculation for cerebral perfusion pressure (CPP)
CPP = MAP - ICP
what is normal cerebral perfusion pressure (CPP)
60 to 100 mm Hg.
cerebral perfusion pressure (CPP) <50mmHg means…
ischemia and neuronal death
HINT HINT we are in trouble if the lactic acid level is
> 4
with lactic acidosis the cerebral blood vessels
dilate more
what can be given for metabolic acidosis
bicarb
increase ICP is
life threatening
Common causes of increased ICP include
*a mass (e.g., hematoma, contusion, abscess, tumor) and cerebral edema (associated with brain tumors, hydrocephalus, head injury, or brain inflammation).
HINT HINT s/s of increase ICP
o Altered level of consciousness (earliest indicator)
o Headache, vomitting
o Abnormal respirations
o Rise in BP, slowing of pulse
o Pupil changes
hydrocephalus
accumulation of fluid in the spaces of the brain (can cause incresed ICP)
intervention for hydrocephalus
ventricularperitoneal shunt
cerebral edema
*increased accumulation of fluid in the extravascular spaces of brain tissue.
Causes of cerebral edema
*Brain tumor, abscess, toxins
*Fluid shift - extracellular/intracellular, SIADH, glucose shifting (HHS,DKA)
*Cerebral spinal fluid, hydrocephalus
what are the major complications of increased ICP
*inadequate cerebral perfusion and cerebral herniation.
HINT HINT cerebral herniation
a downward displacement of the brain into the brainstem
intervention for cerebral herniation n
OPEN UP THE SKULL and MEDICAL EMERGENCY
diagnostic studies for cerebral edema
*CT scan / MRI / PET
*EEG
*Cerebral angiography
*ICP and brain tissue oxygenation measurement
*Doppler and evoked potential studies
HINT HINT what diagnostic study CANNOT be done with increased ICP
NO lumbar puncture due to risk of herniation going from closed compartment to open compartment
HINT HINTGlasgow Coma Scale (GCS)
scale used to assess the level of consciousness
eyes opening, verbal, motor
8 and less is considered coma
how do we measure ICP
use pressure transducer (can be placed in various areas of the brain depending on where the bleed or excess CSF is )
where is the pressure transducer placed when measuring ICP
placed mid ear
what do we do when moving a patient with a pressure transducer
Be fore you change their position you turn OFF then re zero and calibrate
HINT HINT what drug is given for cerebral edema
mannitol
HINT HINT
Mannitol (Osmitrol)
Mannitol (Osmitrol)
Osmotic diuretics. Pull fluid from tissues into blood vessels
-Decrease intracranial pressure related to cerebral edema.
HINT HINTwhat kind of solution is used to manage increased ICP
hypertonic solution
HINT HINT hypertonic solution causes salt levels to…
RISE
Solute concentration is greater than that inside the cell; cell loses water
HINT HINT what corticosteroid is used for cerebral edema
*Dexamethasone(decadron)
what do we monitor with a patient on Dexamethasone(decadron)
*Monitor fluid intake, serum sodium and glucose levels
what should be given with Dexamethasone(decadron)
antacids, H2 receptor blockers, proton pump inhibitors becuase corticosteroids can cause ulcers so we want to protect the gut
anyone with head trauma/increased ICP should be on
antiseizure medications/seizure precautions
medication for emergent seziure activity
*Benzodiazepines(Lorazepam)
maintenance medication for seizure
*Phenytoin(Dilantin)
ways to cool a client
alternate Tylenol and ibuprofen or sponge them and pack in ice or cooling blanket
ways to warm a client
bear hugger or warm blanket, heating pad, warm IV fluids
when a patient is on sedatives for increased ICP what should be done?
sedation vacation so that you can assess the neuro function
scores for GSC
The highest GCS score is 15 for a fully alert person, and the lowest possible score is 3. A GCS score of less than or equal to 8 is generally indicative of coma, and mechanical ventilation should be considered.
clinical manifestations of increased ICP
*Change in level of consciousness
*Flattening of affect → coma
*Change in vital signs
*Cushing’s triad
*Change in body temperature
*ocular changes
*↓ In motor function
* BADHeadache
* projectile Vomiting
interventions for projectile vomiting
NPO, may need NG, antiemetics
Ocular signs of increased ICP
*Unilateral pupil dilation
*Sluggish or no response to light
*Inability to move eye upward
*Eyelid ptosis
*Diploplia,
*blurred vision,
*EOM changes
*Pupillary reflex
*Corneal reflex
Cushing’s triad
widened pulse pressure, hypertension, bradycardia, irregular respirations
HINT HINT Decerebrate posturing
extensor posturing
HINT HINT Decorticate posturing
flexor posturing extension of the legs and internal rotation and adduction of the arms with the elbows bent upward indicates damage to cortex
Which posturing is worse?
decerebrate
maintenance of airway for increased ICP
*Elevate head of bed 30 degrees
*Suctioning needs-Keep suctioning to a minimum
*Monitor ABGs-hypoxia-hypercapniaàvasoactive/constricts
*Maintain ventilatory support
how do we determine if we need suction
Coughing, sats dropping, stuff is coming out of mouth, listen to breath sounds, you can feel it in the chest
how to minimize abdominal distention
*NG tube for clients WITHOUT FACIAL OR BASAL skull fractures-use oral route instead
*Pain and anxiety management
*Opioids-fentanyl less effect on brain perfusion/O2
*Propofol (Diprivan)-short duration, can assess
*Dexmedetomidine (Precedex)
*Neuromuscular blocking agents-paralyzers
*Benzodiazepines-avoided most times
monitoring fluid and electrolyte balance
*Monitor IV fluids
*Daily electrolytes-
*Monitor for DI or SIADH (swelling pushed on pituitary gland)
what are things that can increase ICP that need to me minimized
Valsalva maneuver, coughing, sneezing, suctioning, hypoxemia, and arousal from sleep
Interventions to optimize ICP and CPP
*HOB elevated appropriately-30 degrees
*Prevent extreme neck flexion
*Turn SLOWLY
*Avoid coughing, straining, Valsalva
*Avoid hip flexion
Protection from self-injury
*Seizure precautions
*Quiet, nonstimulating environment
Benign brain tumors:
*Benign brain tumors do not contain cancer cells: usually, benign tumors can be removed, and they seldom grow back.
*
*The border or edge of a benign brain tumor can be clearly seen. Cells from benign tumors do not invade tissues around them or spread to other parts of the body.
issue with brain tumors
benign tumors can press on sensitive areas of the brain and cause serious health problems.
Malignant brain tumors:
*Malignant brain tumors are generally more serious and often is life threatening. It may be primary or secondary
*They are likely to grow rapidly and invade the surrounding healthy brain tissue.
primary brain tumor
the tumor originate from the brain tissue
Secondary brain tumors
metastasis from others tumor elsewhere in the body
Risk factors of the brain tumor
*Being male
*Race
*Age
*Family history
*Being exposed to radiation or certain chemicals at work
Signs and symptoms of brain tumor
*Decrease in level of consciousness such as confusion and lethargy.
*
*Headache most common in the early morning and made worse by coughing or strainingVomiting
*
*Papilledema ( edema of optic nerve) and visual disturbance
*
*Alteration in mental status.
*Vomiting
*
*Alteration in mental status.
localized symptoms of brain tumor
*Aphasia
*Personality changes as in case of frontal lobe tumor
*Sensory defects ( smell, hearing).
*Seizures.
*Motor abnormalities
HINT HINT when is a spinal tap used
use in diagnosis of brain tumor but NOT for increased ICP
Treatment of brain tumor
*A variety of medical treatment modalities, including chemotherapy and radiotherapy, are used alone or in combination with surgical resection.
*Supportive care include:
*Steroids
*Anticonvulsant drugs
