Troubled Mind: The Lowdown on Increased ICP
It’s a delicate balance in the skull—until something goes awry.
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Objectives
- Review the anatomy of the human skull
- Describe the effects of increased cranial pressure (ICP)
- Discuss management of ICP
Steve, a paramedic, and Dave, an EMT, are dispatched with an engine to a loading dock behind a local nightclub for an injury from an assault. Upon arrival, they note the presence of a small crowd, but police wave them in, indicating the scene is safe. The crew finds a 42-year-old male lying supine on the ground, unconscious, with snoring respirations.
While Steve calls for an ALS assist, Dave immediately places the patient’s cervical spine in a neutral inline position and opens the airway with a jaw thrust. Steve then inserts an oropharyngeal airway and connects a bag-valve mask to high-flow oxygen. Dave notes the patient’s airway is now clear, respirations are about 8/min. and irregular with shallow tidal volume, and there is a strong bradycardic carotid pulse. Dave assists the patient’s shallow ventilations, adding enough additional tidal volume to result in normal chest rise and fall, and adds a few ventilations per minute to bring the respiratory rate to 12.
As he exposes the patient and begins a rapid trauma assessment, Steve gets the story from the gathered crowd, who turn out to be the patient’s friends. They report that the patient, whose name is Mike, came out to this area to make a phone call. When he did not return after a few minutes, they looked for him, found him like this and called 9-1-1. The bystanders report Mike has a history of hypertension for which he takes an unknown medication. Steve’s rapid trauma exam reveals a contusion and crepitus to the left temporal region of the skull and a dilated and sluggish left pupil. An EMT from the engine obtains a set of vital signs and reports a heart rate of 48/min, respiratory rate of 12/min with BVM assist, and a blood pressure of 210/140. With the help of the EMTs from the engine, the patient is fully immobilized and moved to the ambulance for transport to the trauma center. An EMT from the engine continues BVM ventilation while Steve repeats his rapid trauma assessment.
Introduction
Increased intracranial pressure (ICP) is an increase of the normal pressure within the skull, and can occur as a result of both traumatic and medical etiologies (Table 1). An increase in ICP is a serious and life-threatening medical emergency. In addition to possibly being caused by injury, increased ICP will result in brain injury if allowed to progress unabated. Whether the result of direct injury or a medical cause, increased ICP can damage or alter the function of areas of the brain and restrict blood flow into it.
The clinical manifestations of increased ICP range from subtle in its early phases to profound when there is substantial rise in pressure. Recognition of the signs and symptoms associated with increased ICP is necessary to both initiate proper prehospital care and ensure rapid transport to an appropriate facility. Understanding the anatomy and physiology of the brain as well as the pathophysiology of increased ICP is useful in identifying and understanding the treatment of this condition. This article explores the pertinent anatomy and physiology of the brain and the pathophysiology of increased ICP to help improve its prehospital management.
