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According to MONRO-KELLIE HYPOTHESIS : Intracranial vault is an enclosed space. When the volume of any of these components increases, one or both of the other components must decrease proportionally or there will be an increase in ICP.
Intracranial pressure (ICP) is the pressure that is produce by the three component in the intracranial vault. Normal ICP is less than15mmHg Cerebral perfusion pressure (CPP) is a pressure at which the brain tissue is perfuse and is used to estimate an adequacy of cerebral blood flow. CPP = MAP ICP. MAP = SBP+2DBP/3 Normal CPP is 60- 100mmHg. If CPP less than 60mmHg will cause hypoperfusion and cerebral ischemia. If CPP more than 150mmHg will disrupt the blood brain barrier and cause hyperperfusion and potential for cerebral edema.
Brain matter Cerebral oedema due to trauma, meningitis Space occupying lesion, eg. Tumour/ hematoma, arteriovenous malformation Cerebrospinal fluid Hydrocephalus due to obstruction or reduced absorption .
Compromised cerebral blood flow Worsening cerebral insult and ischemia (irreversible if prolonged) Compensatory hypertension worsening cerebral hemorrhage Conning (brain matter push out from foramen magnum Death
Symptom :
Headache Vomting Photophobia Decrease or absent of reflexes e.g cough gag, corneal reflex.
Sign :
Neck stiffness Reduced GCS Focal neurology Papilooedema Cushings sign :increase SBP, widened pulse pressure, bradycardia, temp: hyperthermia, ICP >15mmHg, respiration: cheyne stokes ( tachypnoea slowly apnea)
Cerebral resuscitation also known as cerebral protection. Cerebral resuscitation are measures taken to maintain a normal ICP of 5-15mmHg and as well protect the brain from secondary brain injury. Secondary brain injuries that occur after initial injury example as a result of hypoxemia/ hypovolemia/ hypotension, hypocapnia/ hypercapnia, hyperthermia, hypoglycemia, cerebral edema or cerebral ischemia. This is to protect6 the brain from getting futher insult and rise to futher neurological deficit.
Maintain patent airway by intubation and ventilation if patient is unable to maintain patent airway or when GCS 8/15. Monitor ABG to keep PaCO2 between 3545mmHg ; PaO2 80-100mmHg (>60mmHg) Rationale : PaCO2< 30mmHg will cause vasoconstriction and lead to cerebral ischemia. PaCO2 >45mmHg will dilate the blood vessel and will lead to cerebral edema. PaO2<60mmHg must be avoided because adequate cerebral perfusion cannot be maintained and can cause cerebral ishchemia
Suctioning.
Suctioning only when needed. To Prevent Isometric Exercise - eg: give IV Fentanyl before suctioning or any procedure Limit each suction episode to <10sec. Limit the number of catheter pass to a minimum. Hyperoxgenation the patient with 100% O2 before, during and after suctioning. Rationale; to prevent hypoxemia that can lead increase ICP.
Prevent seizures.
Administer anticonvulsant therapy to decreased the cerebral metabolism. -Prophylactic anticonvulsant e.g. IV Phenytoin. Calcium Antagonist ( Nimodipime ) - for subarachnoid haemorrhage to reduce cerebral spasm Treatment Of Epilepsy eg. Diazepam or Phenytoin - control seizures to reduce cerebral metabolic rate Steroids eg. Dexamethasone - for brain tumour - reduce cerebral oedema
Maintain normothermia
monitor body temperature as required; 4hourly Administer antipyretic if temperature >37.5 C. Tepid sponging if temperature>38 C Avoid shivering rewarming blanket if temp. <35 C. Rationale : for every 1 C in body temp. increase, the CBF increase 5% to 6% and will increase ICP
Maintain Normoglycemia
Cerebral tissue need glucose for the source of energy and about 20% is utilize by the cerebral. Maintain blood glucose 4-6mmol/L and monitor every 4hours. Administer insulin accordingly to sliding scale Rationale: maintain normal glucose levels to avoids raising cerebral metabolism. If blood glucose >7mmol/L will cause further cerebral edema due to osmosis.