💡 What Is Intracranial Pressure (ICP)?
Intracranial pressure (ICP) refers to the pressure inside the skull caused by brain tissue, blood, and cerebrospinal fluid (CSF). Normal ICP ranges from 7 to 15 mmHg.
According to the Monro-Kellie Doctrine, the brain, blood, and CSF maintain a delicate volume balance. When a disruption—such as trauma, infection, or a stroke—occurs, the body initially compensates by shifting fluids. But if compensation fails, pressure builds, risking cerebral ischemia or brain herniation, which can be fatal.
🚨 Common Causes of Increased ICP
- Traumatic Brain Injury (TBI): Swelling and bleeding from blunt force trauma
- Intracranial Hemorrhages:
- Epidural hematoma – Blood between skull and dura
- Subdural hematoma – Blood between brain and dura
- Intracerebral hemorrhage – Bleeding within brain tissue
- Ischemic Stroke: Causes cerebral edema (swelling)
- Hydrocephalus or Shunt Malfunction: Impaired CSF drainage
- Infections: Meningitis or encephalitis causing inflammation
- Brain Tumors or Mass Lesions: Space-occupying growths raise pressure
🔍 Signs and Symptoms of Elevated ICP
Early Warning Signs:
- Restlessness, confusion, disorientation
- Headache (worsens with coughing or movement)
- Nausea and vomiting
- Visual changes (blurred vision, diplopia)
- Unequal or sluggish pupils
Late Signs (Urgent!):
- Decreased level of consciousness
- Cushing’s Triad: hypertension, bradycardia, irregular respirations (Impending Herniation!)
- Fixed, dilated pupils
- Seizures
- Abnormal posturing (decorticate/decerebrate)
- Loss of brainstem reflexes (gag, cough, corneal)
Pediatric Red Flags:
- Bulging fontanelles
- High-pitched, inconsolable cry
- Poor feeding or lethargy
- Increased head circumference
🧠 How Is ICP Monitored?
1. External Ventricular Drain (EVD)
- Inserted into brain ventricles
- Monitors ICP and drains CSF
- Must clamp drain for accurate readings
Nurse Responsibilities:
- Keep transducer level with the tragus
- Clamp hourly for ICP readings
- Chart CSF output
- Notify provider if ICP > 22 mmHg for 5+ minutes
2. Intraparenchymal Monitor (Bolt)
- Inserted into brain tissue
- Measures pressure only (no drainage)
- Nurses ensure accurate, continuous readings
3. Non-Invasive Methods
- Optic Nerve Sheath Diameter (ONSD)
- Transcranial Doppler (TCD)
- Automated Pupillometry
🔸 Note: Non-invasive tools are supportive but less accurate.
🏥 Nursing Interventions for Managing Elevated ICP
1. Neuro Assessments
- Use Glasgow Coma Scale (GCS)
- Assess LOC, pupils, motor response, speech
2. Positioning
- Elevate HOB to 30 degrees (if not contraindicated)
- Keep head/neck neutral
- Avoid hip flexion or neck rotation
3. Airway & Ventilation
- Prevent hypoxia and hypercapnia
- Maintain SpO₂ > 92%
- May require intubation for airway protection
4. Medications
- Mannitol: Osmotic diuretic (watch serum osmolality)
- Hypertonic Saline (3% or higher): Monitor sodium levels closely
- Sedatives (e.g., Propofol): Reduce cerebral metabolism and agitation
- Antiseizure meds: Keppra, phenytoin, or lamotrigine as prophylaxis
5. Temperature & Seizure Control
- Aggressively treat fever (cooling blankets, antipyretics)
- Prevent shivering (increases metabolic demand)
6. Fluid & Electrolyte Management
- Avoid hypotonic fluids (e.g., D5W)
- Use isotonic fluids unless hypertonic therapy is indicated
- Monitor Na⁺, Cl⁻, and osmolality regularly
- Implement fluid restriction if ordered
🧑⚕️ Long-Term and Multidisciplinary Management
Neurosurgical Collaboration
- Neurosurgeons set ICP thresholds and manage surgical interventions
- Nurses report neuro changes and ICP spikes promptly
Surgical Interventions
- Decompressive Craniectomy
- Removes skull flap to relieve pressure
- Protect surgical site—no direct pressure!
Psychosocial Support
- Provide calm, clear education to patients and families
- Explain monitoring equipment and interventions
- Encourage participation in rehab (PT, OT, speech)
- Offer emotional support and resources
💬 Final Thoughts
As a neuro nurse, your role in detecting early signs, implementing interventions, and collaborating with the care team is vital. You are the first line of defense against devastating outcomes like brain herniation.
Stay curious, stay sharp, and always advocate fiercely for your patients—because in neuro, seconds matter.