Signs and Symptoms of Increased ICP

Conditions associated with chronically increased ICP may first present insidiously. Headaches may be the only symptom of chronic intracranial hypertension. Chronic intracranial hypertension can cause vision loss due to pressure on the optic nerve. Intracranial volume may increase steadily over months with minimal symptoms and no change in the level of consciousness, and yet present dramatically with an acute deterioration of consciousness when compensatory mechanisms are exceeded.

There should be a high clinical suspicion of increased ICP for patients presenting with acute/severe headache, papilledema, and vomiting. The patient may describe the headache as throbbing pain which worsens with actions that further increase ICP such as coughing, sneezing, recumbency or exertion. Other initial signs and symptoms of increased ICP include nausea, blurred vision, restlessness, irritability, and confusion. The clinical presentation of AIH can be mistaken for other problems, such as drug or alcohol intoxication, migraine headache, infection, or post-ictal state. 

Level of consciousness will decrease progressively as ICP gets worse. The Glasgow Coma Scale (GCS) is the most common scoring system used to objectively describe the patient’s level of consciousness. The GCS is composed of three objective tests: eye, verbal, and motor responses. The lowest possible total GCS is 3, indicative of deep coma, while the highest is 15. GCS scores help facilitate communication among healthcare providers and provide guidance for diagnostic workup and therapeutic intervention.
 

Glasgow Coma Score (Teasdale & Jennett, 1974)
Feature	Response	Score
Best eye response If local injury, edema, or otherwise unable to be assessed, mark "Not testable (NT)"	Spontaneously To verbal command To pain No eye opening Not testable	4 3 2 1 NT
Best verbal response If intubated or otherwise unable to be assessed, mark "Not testable (NT)"	Oriented Confused Inappropriate words Incomprehensible sounds No verbal response Not testable	5 4 3 2 1 NT
Best motor response If on sedation/paralysis or unable to be assessed, mark "Not testable (NT)"	Obeys commands Localizes pain Withdrawal from pain Flexion to pain Extension to pain No motor response Not testable	6 5 4 3 2 1 NT

 

Increased ICP may cause protrusion or herniation of brain tissue through one of the rigid intracranial barriers. Signs of brain herniation include pupillary dilatation, hemiplegia, impaired oculocephalic movements, increased motor tone, flexion or extension to pain (posturing), and respirations containing sighs, deep yawns, or pauses. The Cushing reflex, also known as Cushing’s triad, consists of hypertension, bradycardia, and diminished respiratory effort. Presence of Cushing’s triad is a poor diagnostic sign and indicates impending brainstem herniation. Prompt emergency treatment is warranted.

Managing Increased ICP

Nursing measures are targeted to assessing for changes in the neurologic exam, preserving cerebral blood flow through optimizing cerebral perfusion pressure (CPP), and protecting the brain from secondary injury.
 

The ABCs of Managing Increased Intracranial Pressure (Hussein et al, 2017)
	Strategy	Intervention
A	Airway	Monitor airway patency. Intubation, if needed, to prevent hypoxemia and hypercapnia.
B	Blood pressure	Monitor cerebral perfusion pressure (CPP). Maintain adequate blood pressure to optimize CPP. Avoid hypotension.
C	Calm	Decrease stimulation by providing a calm, quiet environment. Minimize nursing interventions and space them out as able. Provide intravenous (IV) sedatives as needed.
D	Decompression	Insert a nasal or oral gastric tube to decompress the stomach to decrease vomiting. Note: Nasogastric tubes are contraindicated with basilar skull fractures or intranasal surgery, such as transsphenoidal pituitary resection.
E	Edema	Monitor intracranial pressure if a catheter has been placed. Monitor for changes in the neurologic exam. Administer osmotic diuretics or hypertonic saline as ordered.
	Eyes	Monitor pupillary responses to light and corneal reflexes.
	Elevate the head	Raise the head of the bed to 30 degrees to facilitate jugular venous outflow. Maintain neck in neutral position.
F	Fluids and electrolytes	Monitor for fluid and electrolyte imbalances that might indicate abnormal anti-diuretic hormone (ADH) levels. Administer isotonic IV fluids and electrolytes as ordered.
	Food	Provide enteral nutrition either through a feeding tube or orally if cleared by a speech pathologist.
	Family	Provide family education and support. Participate in advanced care planning.
G	Glasgow Coma Scale (GCS)	Monitor GCS hourly and report changes to a provider.
H	Hip flexion	Avoid hip flexion which increases intra-abdominal and intrathoracic pressure.
	Hyperventilation	Hyperventilation is used to lower carbon dioxide levels if other measures to lower ICP are ineffective.
	Hyperthermia	Prevent hyperthermia to lower the metabolic requirements of the brain.
	Herniation	Monitor for impending herniation: unilateral or bilateral pupil dilation, coma, posturing, Cushing’s reflex (hypertension, bradycardia, bradypnea).
I	ICP monitoring	Monitor ICP and inform provider of sustained ICP>20. Monitor the effect of nursing care on ICP and minimize treatments or stimuli which increase it.
	Infection	Strict aseptic technique when applying or changing dressings to ICP monitoring devices or ventricular drainage systems.

The prompt recognition and management of patients with increased ICP requires knowledge of at-risk patient populations and the signs and symptoms of elevated ICP. Acute intracranial hypertension resulting from rapid elevation of intracranial pressure is a medical emergency requiring immediate stabilization of airway, breathing and circulation followed by immediate brain imaging for confirmation and diagnosis of the underlying etiology. ICP monitoring, and in certain cases CSF drainage, is a cornerstone of management. The neuroscience ICU nurse provides a calm, quiet environment, vigilant monitoring, and interventions to optimize cerebral blood flow and prevent complications.