Increased intracranial pressure: Treatment of intensive care

2021-07-31 10:26 PM

Increased intracranial pressure, which needs to be diagnosed early and managed aggressively because of the risk of very rapid brain collapse, a fatal complication, or irreversible damage

Increased intracranial pressure

Increased intracranial pressure is a potentially devastating complication of severe neurological damage. Elevated intracranial pressure can complicate trauma, central nervous system tumors, hydrocephalus, hepatic encephalopathy, and impaired central nervous system venous bleeding. Successful management of patients with elevated intracranial pressure requires prompt recognition, judicious use of invasive monitoring, and treatment aimed at both reducing ICP and reversing the underlying cause of the disease. it.

Intracranial pressure is usually ≤15 mmHg in adults and increases in intracranial disease present at pressures ≥ 20 mmHg. Intracranial pressure is usually lower in children than in adults. A homeostatic mechanism stabilizes intracranial pressure, with transient elevations associated with physiological problems, including sneezing, coughing, or Valsalva maneuvers.

Elevated intracranial pressure needs to be diagnosed early and managed aggressively because of the risk of very rapid brain collapse, which is a fatal complication or irreversible damage. Consequences of increased intracranial pressure are cerebral edema, increasing cerebral ischemia, creating a pathological spiral.

In an adult, the volume of the skull is about 1500ml, including 80% of the brain tissue, 10% of the blood, and 10% of the cerebrospinal fluid.

Cerebral perfusion pressure greater than 60 mmHg.

 Cerebral perfusion pressure = mean blood pressure – intracranial pressure.

Compensatory adaptive mechanisms such as cerebrospinal fluid draining toward the spinal cord increased permeation across the arachnoid membrane into the superior sagittal sinus and decreased cerebral blood volume.

Definite diagnosis

Clinical

Awake patient

Headache is usually a progressive pain that may be diffuse or localized.

Vomiting: common in posterior fossa causes.

Visual disturbances: double vision, blurred vision, decreased visual acuity, ophthalmoscopy with papilledema.

Nervous disorders: somnolence, lethargy.

Coma patient:

Waking up suddenly in a coma or in a deeper coma.

There is an increase in muscle tone.

Autonomic dysfunction (which is a severe sign):

Fast or slow heart rate, increased blood pressure or decreased blood pressure.

+ Respiratory disorders: rapid, deep breathing or Cheyne-Stocks.

+ Disorders of body temperature regulation: high fever

Signs of brain damage:

+ Relapse of the temporal lobe: paralysis of the III cord, dilated pupils.

+ Cerebellar amygdala: rapid breathing or stop worshiping.

+ Central cerebral insufficiency: showing damage from top to bottom.

Subclinical

Blood tests: can determine the cause of hyponatremia.

CT scan of the skull: helps diagnose the cause of increased intracranial pressure.

+ Brain edema, brain structure is pushed, midline structure is changed

+ Dilated ventricles: due to obstruction. The circulation of cerebrospinal fluid.

+ Can see brain bleeding, cerebral ischemia, brain tumor, brain abscess, ...

Cranial MRI: gives more insight into brain damage.

Cerebral angiography: identify cerebral vascular malformations.

Lumbar puncture: when meningitis is suspected, allow the cerebrospinal fluid to drain slowly.

Diagnose the cause

Traumatic brain injury.

Cerebral bleeding: in the brain parenchyma, ventricles, subarachnoid hemorrhage.

Brain tumor

Nerve infections: encephalitis, meningitis, brain abscess.

Hydrocephalus.

Other likely causes of increased intracranial pressure:

+ Increased blood C02; decreased blood oxygen.

+ Artificial ventilation using PEEP.

+ Increased body temperature.

Hyponatremia.

+ Convulsions.

Differential diagnosis

Coma: hyperosmotic coma, ketoacidosis, hypoglycemia, hepatic coma, ...

Blurred vision: physical diseases of the eye.

Headache: peripheral nerve causes, vasomotor disorders. I.

Treatment

Internally medical treatment

Have the patient lie still if awake.

Head height 30°-45°C.

Ensure respiration: breathe oxygen. Patients who are comatose and have respiratory disorders require intubation and artificial ventilation (avoid using PEEP), maintaining PaCO 2 from 26 to 30 mmHg.

Circulatory Resuscitation:

Attention: maintain the patient's blood pressure higher than normal or baseline blood pressure (systolic blood pressure 140-180 mmHg, diastolic blood pressure < 120 mmHg) to ensure cerebral perfusion pressure (cerebral perfusion pressure): 65-70mmHg), keep blood osmolality 295 to 305mOsm/l.

If low blood pressure:

+ Adequate fluid infusion: based on cerebral perfusion pressure, do not infuse glucose 5% and NaCI 0.45%.

+ Blood pressure still does not meet the requirements: use intravenous dopamine.

+ Treatment of hypertension when: systolic blood pressure > 180 mmHg and/or diastolic blood pressure > 120 mmHg with renal failure.

If systolic blood pressure > 230 mmHg and/or diastolic blood pressure > 140 mmHg:

Nitroprusside intravenous infusion: 0.1 - 0.5μg/kg/min, maximum 10μg/kg/min.

Nicardipine (Loxen) IV infusion: 5 - 15mg/hour.

+ If systolic blood pressure: 180 - 230 mmHg and/or diastolic blood pressure 105 - 140 mmHg: take a blocker: labetalol (if the heart rate is not bradycardia < 60 beats/min).

+ If systolic blood pressure < 180 mmHg and/or systolic blood pressure < 105 mmHg: take a blocker (if the heart rate is not bradycardia < 60 beats/min. Or an ACE inhibitor such as: Enalaprin 10mg/tablet; Perldopril 5mg/tablet). .

+ Repeated intravenous urosemide diuretic if antihypertensive drugs are not effective.

Mannitol is only used when there is cerebral edema: 0.25 - 1 g/kg/6 hours intravenous infusion over 30 minutes; Do not use more than 3 days.

Intravenous sedation: Thiopental (50-100mg/hour); Propofol (5 - 80mcg/kg/min).

+ Anesthesia dose: reduce cerebral edema, reduce the need for oxygen in the brain.

+ Deepen coma, lower blood pressure. consciousness and blood pressure should be closely monitored.

Corticosteroids: indicated in a brain tumor, brain abscess. Do not use in case of high blood pressure.

+ Methylprednisolone: ​​40-120mg intravenously, maintain 40mg/6 hours.

+ Dexamethasone: 8mg IM or IV, maintain 4mg/6 hours.

Adjust electrolyte water:

Treatment of hyperthermia: paracetamol by inhalation or intravenous infusion.

Surgical treatment

When the cause is known, medical treatment is not effective.

Hydrocephalus: surgery to drain the ventricles.

Large hematoma: remove a hematoma, resolve bleeding due to malformation.

Brain tumor: Often difficult.

Brain abscess: after stable medical treatment, the abscess is localized.