Raised Intracranial Pressure - Case Study Example

QUESTION Joyce was assessed with raised intracranial pressure because of the fact revealed in her assessment data. It should be d that intracranial pressure or ICP is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal pressure. ICP is almost always indicative of severe medical problems. The pressure itself can be responsible for further damage to the central nervous system by decreasing blood flow to the brain or by causing the brain to herniate (push through) the opening in the back of the skull where the spinal cord is attached. Sudden herniation through the foramen magnum (back of the skull) is fatal (Kennedy, 2001). Increased ICP is defined as a sustained elevation in pressure above 20mm of Hg/cm of H20. The craniospinal cavity may be considered as a balloon. During slow increase in volume in a continuous mode, the ICP raises to a plateau level at which the increase level of CSF absorption keeps pace with the increase in volume. Intermittent expansion causes only a transient rise in ICP at first. When sufficient CSF has been absorbed to accommodate the volume the ICP returns to normal. Expansion to a critical volume does however cause persistent raise in ICP, which thereafter increases logarithmically with increasing volume. The ICP finally rises to the level of arterial pressure, which it self begins to increase (Thamburaj, 2004). Raised ICP causes arterial hypertension, bradycardia (Cushing's response) and respiratory changes. It is traditionally accepted that hypertension and bradycardia are due to ischaemia or pressure on the brainstem. There is also a suggestion that they could be due to removal of supratentorial inhibition of brainstem vasopressor centers due to cerebral ischaemia and that bradycardia is independent of the rise in blood pressure. The respiratory changes depend on the level of brainstem involved. The midbrain involvement results in Chyne-Stokes respiration. When midbrain and pons are involved, there is sustained hyperventilation. There is rapid and shallow respiration when upper medulla involvement with ataxic breathing in the final stages. Pulmonary edema seems to be due to increased sympathetic activity as a result of the effects of raised ICP on the hypothalamus, medulla or cervical spinal cord (Thamburaj, 2004). There are observable signs that point out that Joyce is indeed suffering from increased intracranial pressure. The most significant of which was the dilation of the left eye. It was revealed in the assessment data that Joyce's pupil in the left eye is greater than her right eye. This only shows that there is malfunctioning in her internal head part or within the brain, particularly in the right side of her brain. it should be noted that dilation of the eyes must be equal on both sides as a result of normal functioning inside the brain. And because the left eye's pupil is dilated more than the right eye, it can only be assumed that there is a very strong pressure inside the brain, forcing the left eye's pupil to be dilated heavily. Another significant data that shows that the patient is suffering from raised intracranial pressure is her abnormal blood pressure, body temperature and intracranial pressure rates. All of these three aspects are beyond and/or under the normal limit of an average person. Joyce's blood pressure is very low (the normal blood pressure is 110/70 - 120/80). This could only mean that there is something wrong in her blood circulation which can be affected by the electrolytes and or malfunctioning of some of her body organs, nerves and systems. Her body temperature is beyond the normal limit which is 37 degree Celsius to 37.5 degree Celsius (Dunn, 2002). Abnormal blood pressure also shows that her blood circulation and body organs are not working properly thereby affecting the production of body heat. Joyce's intracranial pressure is also high and over the limit of the normal rate. This reflects that there is an increased intracranial pressure, might be because her body system is trying very hard to cope with the malfunctioning or possible absence of mobility in some of her body organs that's why there is a need to increase the pressure (Dunn, 2002). It can then be concluded that Joyce is suffering from a raised intracranial pressure which is the result of the interconnected malfunctioning of her entire body organs and systems. There is an obvious malfunctioning due to the impact of the accident. It should be noted that these responses of the body organs are just normal and can be expected to anybody who suffered such strong impact of accident. Regardless of the age or of the gender, anybody of normal body functioning will demonstrate the same body reactions with that intense impact of the accident (Oertel, Kelly, Lee, et al, 2002). QUESTION 2 It is widely accepted fact that the increased ICP is a temporary phenomenon lasting for a short time unless there is a fresh secondary injury due to a clot, hypoxia or electrolyte disturbance. Hence, the treatment is primarily aimed at preventing the secondary events (Thamburaj, 2004). Treatment and management of increased ICP is clearly not a very easy task. The best treatment for increased ICP is the removal of the causative lesion such as tumors, hydrocephalus, and hematomas (Thamburaj, 2004). The first step is to find the cause of the raised intracranial pressure and remove it if possible. If there is excessive cerebrospinal fluid as in hydrocephalus then shunt procedure or external drainage should be instituted. If there is a resectable tumor then this should be removed. In cases where there are no surgically treatable cause efforts should be directed at reducing intracranial pressure by one of the following means: a) Osmotic diuretic, which is the act of dehydrating the brain. This can be achieved by removing extracellular fluid by creating an osmotic gradient across the capillary wall. b) The use of steroids. Steroids are mainly used to reduce brain swelling around brain tumors. c) Through CSF drainage, which is an effective and rapid way of reducing intracranial pressure in cases where ventricles are visible and can be cannulated. d) By hyperventilation. The aim of hyperventilation is to reduce the PCO2 to a level around 30 mm/Hg. Low PCO2 will cause vasoconstriction and reduced intracranial blood volume. e) Through barbituration. Barbiturate is used to induce deep coma, where there is a reduction in metabolic rate, oxygen consumption and CO2 production. This method is used only when all other means of treatment failed (http://www.health.adelaide.edu.au/paed-neuro/pressure.html, 2004). After all this information on increased ICP, the symptoms, the probable causes, and the best treatment were given, the big question now here is "what will happen if you fail to decrease or prevent the continuous increase of ICP". One of the scariest things that will happen to a person if he/she failed to treat her increased ICP is he/she to suffer from herniation of the brainstem, and this is fatal. So, one must really monitor him/herself from intracranial pressure and prevent this from increasing. Because of the above stated information, immediate action from the whole team of medical professionals is then very important for Joyce's case, especially during the next 6 hours of the patient. The team of medical professionals who will play a detrimental role in this aspect include: general practitioners (GPs), physiotherapist and neurologists and the nurses. Below are the top three of the activities that should be performed for Joyce to ensure her survival and/or immediate recovery: 1. Tube feeding and supportive treatment via fluid replacement The GP will be the one to initiate this. He will be the one to prescribe what type of tube feeding and supportive treatment is necessary for Joyce. It will also be his responsibility to give specific and clear details as to the amount or the frequency of feeding and/or fluid replacement should be applied (Sahuquillo and Arikan, 2006). Then it will be the nurses' responsibility to facilitate such prescription. They will be the one to ensure that tube feeding is given at the right quality, right quantity, and in the most appropriate manner. At the same time it will be nurses' duty to ensure that the patient is responding positively with the tube feeding and supportive treatment - no negative or adverse reaction or indications of trauma whatsoever. The evaluation criteria for top most intervention parameter are (Tokutomi, Morimoto, Miyagi, et al, 2003): a. Blood chemistry (electrolytes and oxygen level) is within normal range indicative signs of gradual improvement are observed. b. Blood pressure is improving or normalizing 2. Antibiotic treatment (to prevent infections) and supportive medicine including blood anti-coagulants (to prevent blood clots in the brain) and diuretics (to facilitate in fluid drainage, mainly from the brain). It will be the GPs responsibility to prescribe the right medication or antibiotic treatment and other supportive medicine is necessary for Joyce's case. He will be the one to give the right specifications for the nurses to facilitate. It is then clear that right after the GP has prescribed the medication, it will be the nurses who will ensure that such prescription is followed. It will be the nurses' duty to check on the patient on a regular basis and make sure that the patient is being responsive to the antibiotic treatment and other supportive medicine being given. It should not be forgotten that it will be the nurses who will also facilitate giving all the prescribed medicine according to the frequency and amount stated by the GP (Dunn, 2002). The nurses should not ask anybody, even the relatives or immediate family of Joyce to give such medication. This is because the medication will be given intravenously and only the skilled medical professionals are trained to do that. The evaluation criteria that can be used to ascertain whether or not Joyce is responding positively with the prescribed antibiotic treatment and supportive medicine are: a. Normal blood chemistry especially white blood cell or WBC and platelet count - an increased white blood cell count is an indication of infection, hence the GP and the nurses should make sure that WBC is maintained within normal range (Sahuquillo and Arikan, 2006). b. Absence of blood clots or fluid accumulation in the brain via CT scan - this is particularly important to be checked on a regular basis because blood clots normally occur in the most unexpected time. Blood clots should never occur to Joyce because this is a very having clots will mean for a more fragile state. If a clot was noticed or recognized, every possible and careful approach should be done to remove such clot (Sahuquillo and Arikan, 2006). 3. Neurological assessment and physiotherapy Neurological assessment and physiotherapy of Joyce can only be done by two groups of specialists called Neurologist and Physiotherapists. The neurologists will perform the much needed CT scan of Joyce to check for any brain damages, haematoma and blood clots. It should be noted that this should be done not only once but several times, on a regular basis or as prescribed by the GP. Physiotherapy (by Physiotherapists), on the other hand, is to check the motor and body functions, and to prevent muscle atrophy due to its immobility (Sahuquillo and Arikan, 2006). Since there are already indicative signs that Joyce has a raised intracranial pressure, immediate actions should be done that no further damage or problems would occur in her brains and to all of her body organs (Sahuquillo and Arikan, 2006). Her internal organs should still be responding positively while her physical body parts should also be performing actively even if there are scratches, wounds, fracture whatsoever. The evaluation criteria for this 3rd top most priority that should be done to Joyce are (Schwarz, Georgiadis, Aschoff, et al, 2002): a. Normal brain structure which can be assessed via CT scan, normal intracranial pressure and regular pupil dilation of both eyes b. Normal motor functions - Normal motor functions can be recognized by checking all body parts if they are still working out properly just like any other normal being. For example checking the body reflex points if they still react accordingly. This may all be seemingly simple tests but these are very critical. For one, if an abnormal brain structure is observed and will not be fixed or normalized immediately, Joyce might be living the rest of her life abnormally. She might become retarded or will need to be assisted by a specialist for the next years of her life. Meanwhile if an abnormal motor function is found and would not be fixed as soon as possible, this would also mean that there are a number of activities which cold not be anymore performed by Joyce. Like for example if her feet muscles, knees or toes are not working anymore, this could mean that she will not be able to walk again and will have to live the rest of her life in a wheelchair (Schwarz, Georgiadis, Aschoff, et al, 2002). Of course, these are the worst possible incidents that might happen to Joyce. This is the very reason why specialists are the one to perform this 3rd activity to make sure that the result will be assessed properly. These specialists would like to ensure that these retardation and/or permanent immobility will not happen to Joyce if that is possible. They will have to see to it that there are many possible alternatives or corrective actions that should be given to Joyce if ever an abnormality is found. They will be the one to suggest or prescribe such corrective measures. Indeed, immediate but certain actions should be done to Joyce in the next 6 hours right after she was admitted and tested in the hospital. Immediate because any further damage to her body system (whether internal or physical) should be avoided. Certain or sure because there is no room for mistake in his very critical situation where human life is at stake. Works Cited: Dunn LT; Raised intracranial pressure.; J Neurol Neurosurg Psychiatry. 2002 Sep;73 Suppl 1:i23-7. Intracranial Pressure. 2004. Kennedy, Victoria. Increased Intracranial Pressure. November 2001. AllRefer.com. April, 2004. < http://health.allrefer.com/health/increased-intracranial-pressure-treatment.html> Neurological Dysfunction - Brain. 2004. Pathoplus Page. Oertel M, Kelly DF, Lee JH, et al; Efficacy of hyperventilation, blood pressure elevation, and metabolic suppression therapy in controlling intracranial pressure after head injury.; J Neurosurg. 2002 Nov;97(5):1045-53. Sahuquillo J, Arikan F; Decompressive craniectomy for the treatment of refractory high intracranial pressure in traumatic brain injury.; Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003983. Schwarz S, Georgiadis D, Aschoff A, et al; Effects of hypertonic (10%) saline in patients with raised intracranial pressure after stroke.; Stroke. 2002 Jan;33(1):136-40. Thamburaj, Vincent. Intracranial Pressure. 2004. Neurosurgery on the Web. http://www.thamburaj.com/intracranial_pressure.htm Tokutomi T, Morimoto K, Miyagi T, et al; Optimal temperature for the management of severe traumatic brain injury: effect of hypothermia on intracranial pressure, systemic and intracranial hemodynamics, and metabolism.; Neurosurgery. 2003 Jan;52(1):102-11; discussion 111-2. Read More