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Introduction   

Caring for a patient with traumatic injuries means paying attention to a lot of different signs and symptoms at once, which is why these patients are often kept in the intensive care unit or other higher level of care. A patient may initially be considered stable enough for a medical, surgical, or telemetry floor but then may need to be transferred to a higher level of care because of a worsening condition. One sign of a worsening condition is increasing intracranial pressure (ICP). Increased ICP can cause seizures, herniation of brain tissue, brain death, or patient death. It is important that all nurses are aware of the signs of increased ICP so they can act quickly to support their patients and prevent a potentially fatal outcome.   

Case Study# 1 

Steven is a 30-year-old patient in a motorcycle accident without wearing a helmet. He was taken to the ER and upon his arrival his assessment showed he was able to answer questions and informed the nurse he had a bad headache. His Glasgow scale was 13, VS 98.1. HR 96, RR 22, BP 142/78. After an hour had passed the nurse reassessed the patient and his Glasgow scale was now 6, he was lethargic, vomiting with altered mental status and VS 102.6, HR 50, RR 12, BP 178/98. Steven is taken for a CT scan and admitted to the ICU. 

Case Study # 2 

Tracey is a 10-month-old patient that was brought to the hospital by her parents with complaints of change in LOC, decreased appetite, decreased hydration, vomiting, increased sleepiness. Her assessment show T-103.5, HR 58, RR 12, BP 140/90, bulge in the top of her head. Her parent stated they just returned from a trip to Costa Rica when suddenly Tracey has a seizure. Once stabilized the nurse as the parents about the bulge in Tracey’s head and her mother states it’s from her shunt because she has hydrocephalus. Tracey is immediately admitted to the PICU. 

Case # 3 

Jennifer is a 47-year-old mother of two and is currently pregnant with her third baby at 29 weeks gestation. She was sent to the ER by her OBGYN for evaluation because she presented to his office with extreme thirst, severe headache, double vision, and 3+ pitting edema to her lower extremities. Her vital signs were BP 170/100 heart rate 68, respirations 16, and temperature 101.5. Jennifer is admitted into the ICU for evaluation for pre-eclampsia her OBGYN is concerned about neurological complications because he knows women with pre-eclampsia have a 30- 70% direct neurological complication resulting in death and it’s mostly due to intracerebral hemorrhage or cerebral edema (9). 

Review the case studies to answer the learner exercises. 

Causes of Increased ICP 

Increased ICP can be a result of too much of something in the cranial space that is normally there or added pressure from something foreign, intracranial hemorrhage, intracranial infection, hydrocephalus, brain tumor, as well as other neurological conditions (1). 

 A cerebrovascular accident (CVA) or “bleed” can result in increased ICP, as swelling and blood add to the space. Something foreign, such as a tumor, can take up room in an already tight space, increasing the pressure around it. Any cranial surgical procedure can cause swelling, and without an outlet such as a craniotomy, that swelling leads to increased pressure inside the skull. Traumatic injuries, such as a motor vehicle accident, significant fall, or direct head injury, can cause swelling just as a sprained ankle or broken arm, except there is very little room for swelling around the brain. Another cause of increased ICP is a condition called Idiopathic intracranial hypertension (IIH). This is a rare disease that is increasingly getting recognized. It is characterized by raised ICP in the absence of a structural cause in the brain imaging. The presenting symptoms include persistent headache, pulsatile tinnitus, and visual obscuration. The origin of IIH is presently unknown. This condition is sometimes mistaken for migraines (5). 

Consider that the intracranial space contains three major components: cerebrospinal fluid. (CSF), the blood supply, consisting of the network of arteries and veins that supply blood to the brain and parenchymal tissue. These components are enclosed within an effectively rigid skull that can be treated as a closed system. Thus, pressure and volume are related: a change in volume to any one component will result in a commensurate change in ICP (1). Because the volume of the brain is typically fixed, the two most important components contributing to ICP are the cerebral blood flow and the balance between production and absorption or outflow of the CSF. If the volume of either of these two components increases, through events including intracranial hemorrhage or an inability to effectively absorb or drain CSF, without a compensatory decrease in another component, then the resulting net volume expansion will lead to increased ICP (1). 

Pre-eclampsia is considered a precursor to increased intracranial pressure (ICP). According to the International Society for the study of hypertension during pregnancy, neurological complications associated with preeclampsia include seizures, arterial ischemic strokes, subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral venous sinus thrombosis. Preeclampsia associated maternal stroke has high morbidity and mortality rates (9). An antepartum diagnosis of preeclampsia and postpartum diagnosis of preeclampsia are worse after delivery and cause neurological sequelae. The highest risk for a maternal stroke caused by ICP’s is postpartum in the first two weeks after delivery with risk extending up to 12 weeks postpartum (9). 

Swelling can also occur because of fluid shifts. If you remember learning “water follows salt” you may remember that electrolyte imbalances, specifically sodium changes, can cause intracranial pressure changes. Hypernatremia (elevated sodium) can cause increased intracranial pressure because osmotic fluid shifts into the closed cranial space. Vitamin A toxicity has also been linked to increased ICP though it is considered rare (1, 2). Another rare cause of increased ICP is pseudotumor cerebri, an increase in the fluid in the cranial space thought to be caused by either too much CSF production or too little being absorbed (3). The pharmacological treatment of increased ICP should always be guided whenever possible. 

Importance of Monitoring ICP  

Measurement of ICP is pillar for the management of patients in the intensive care unit. The gold standard for monitoring ICP is an invasive or parenchymal probe. All invasive methods carry a risk of infection or intracranial bleeding (6). Invasive ICP monitoring is recommended by international guidelines, to reduce the incidence of secondary brain injury, the complications related to ICP probes could be dependent on the duration of monitoring. Although the risk may be high, the techniques provide an essential tool to facilitate early detection and treatment of acute brain injury and empower the intensive care team with tools to potentially reduce the burden neurologic morbidity in critically ill patients (8). 

Vital Sign Changes 

Increased ICP causes changes in vital signs. Dr. Harvey Cushing recognized what we now refer to as the Cushing’s Triad. The body senses decreased perfusion of brain tissue, so it responds by increasing blood pressure and increasing brain perfusion (4). Since the blood pressure increases, the compensatory mechanism decreases the heart rate. Because of this, we see hypertension and the resulting bradycardia. 

Widening pulse pressure, which is an increase in the difference between the diastolic and systolic pressure, is indicative of increased ICP as the body fights to maintain brain perfusion. Ironically, respirations become decreased and irregular (4). When you think of increasing ICP think of the Cushing’s Triad; hypertension, bradycardia, and decreased/irregular respirations.  

Vital signs are objective, so we can easily see changes on a graph and notice the blood pressure rising or the pulse pressure widening, but that requires having several sets of vital sign readings to review. One important thing to keep in mind is that changes in vital signs are later sign of increased ICP, which means that the condition is severe by the time you may recognize those changes. Before changes in vital signs, the nurse will hopefully notice one of the initial changes in the patient’s behavior, which could signal a problem sooner.   

Behavior Changes 

Early and initial changes in the patient’s behavior, because of ICP could include restlessness, weakness, and/or lethargy. These may be confused with signs of pain or fatigue, so it is important to differentiate and keep in mind your patient’s risk for increased ICP when assessing them. They may also report headache, vision changes, and/or nausea/vomiting. Interestingly, increased ICP is known for causing projectile vomiting though the exact pathophysiology is unknown (1). As the condition worsens, the nurse may notice changes in the patient’s level of consciousness and a decreasing Glasgow Coma Scale (GCS) score.   

As the condition worsens, the patient may develop seizures as the brain starves for oxygen and struggles under increasing pressure. If the pressure is not relieved, the patient may demonstrate posturing (decerebrate or decorticate) and pupil dilation (may be unilateral) because of brain damage. Eye exams may show papilledema, swelling of the optic disc within the eye (usually bilateral) (1). Patients may have all or few of these signs/symptoms, depending on the cause of their increased ICP, their ability to compensate, treatment, severity, and age. Infants may have bulging fontanels since the skull has not fully formed and the intracranial pressure has some room to expand.  

Treatment Modalities of ICP 

Hyperosmolar therapy, acute hyperventilation, temperature modulation, diversion of CSF, surgical decompression, and metabolic suppression (7). Clinicians must be able to select appropriate therapies for initial ICP management based on available evidence while balancing efficacy and safety. The pharmacological treatment of ICP should always be guided by the underlying pathology, being mindful that outcomes are often influenced by multiple factors that may be beyond the awareness or control of the treating team (i.e. comorbidities, rehab potential, associated injuries) (7). 

Conclusion 

Since the early signs of increased ICP can look like many other things, it is important that the nurse be aware of the patient’s risk for increased ICP based on their injury, surgery, or labs. Being aware of your patient’s risks can help you differentiate between a headache caused by lack of caffeine, for example, versus increasing ICP. A patient being seen for an appendectomy or tonsillectomy may not be as concerning as a patient with meningitis, metastatic cancer, or motor vehicle accident. The best bet is to perform regular and consistent neuro exams and pay attention to changes since you could be the one to notice subtle declines before they are fatal.  

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