Identifying the Signs of Increased ICP

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Introduction   

Caring for a patient with traumatic injuries means paying attention to a lot of different signs and symptoms at once, which is why these patients are often kept in the intensive care unit or other higher level of care. A patient may initially be considered stable enough for a medical, surgical, or telemetry floor but then may need to be transferred to a higher level of care because of a worsening condition. One sign of a worsening condition is increasing intracranial pressure (ICP). Increased ICP can cause seizures, herniation of brain tissue, brain death, or patient death. It is important that all nurses are aware of the signs of increased ICP so they can act quickly to support their patients and prevent a potentially fatal outcome.   

Causes of Increased ICP 

Increased ICP can be a result of too much of something in the cranial space that is normally there or added pressure from something foreign. A cerebrovascular accident (CVA) or “bleed” can result in increased ICP as swelling and blood add to the space. Something foreign, such as a tumor, can take up room in an already tight space, increasing the pressure around it. Any cranial surgical procedure can cause swelling, and without an outlet such as a craniotomy, that swelling leads to increased pressure inside the skull. Traumatic injuries, such as a motor vehicle accident, significant fall, or direct head injury, can cause swelling just as a sprained ankle or broken arm, except there is very little room for swelling around the brain. This is also true with infections; without much room for swelling, an infection in or around the brain tissue can cause increased ICP (1).  

Swelling can also occur because of fluid shifts. If you remember learning “water follows salt” you may remember that electrolyte imbalances, specifically sodium changes, can cause intracranial pressure changes. Hypernatremia (elevated sodium) can cause increased intracranial pressure because osmotic fluid shifts into the closed cranial space. Vitamin A toxicity has also been linked to increased ICP though it is considered rare (1, 2). Another rare cause of increased ICP is pseudotumor cerebri, an increase in the fluid in the cranial space thought to be caused by either too much CSF production or too little being absorbed (3). 

Vital Sign Changes 

Increased ICP causes changes in vital signs. Dr. Harvey Cushing recognized what we now refer to as the Cushing’s Triad. The body senses decreased perfusion of brain tissue, so it responds by increasing blood pressure and increasing brain perfusion (4). Since the blood pressure increases, the compensatory mechanism decreases the heart rate. Because of this, we see hypertension and the resulting bradycardia. 

Widening pulse pressure, which is an increase in the difference between the diastolic and systolic pressure, is indicative of increased ICP as the body fights to maintain brain perfusion. Ironically, respirations become decreased and irregular (4). When you think of increasing ICP think of the Cushing’s Triad; hypertension, bradycardia, and decreased/irregular respirations.  

Vital signs are objective, so we can easily see changes on a graph and notice the blood pressure rising or the pulse pressure widening, but that requires having several sets of vital sign readings to review. One important thing to keep in mind is that changes in vital signs are actually a later sign of increased ICP, which means that the condition is severe by the time you may recognize those changes. Before changes in vital signs, the nurse will hopefully notice one of the initial changes in the patient’s behavior, which could signal a problem sooner.   

Behavior Changes 

Early and initial changes in the patient’s behavior as a result of ICP could include restlessness, weakness, and/or lethargy. These may be confused with signs of pain or fatigue, so it is important to differentiate and keep in mind your patient’s risk for increased ICP when assessing them. They may also report headache, vision changes, and/or nausea/vomiting. Interestingly, increased ICP is known for causing projectile vomiting though the exact pathophysiology is unknown (5). As the condition worsens, the nurse may notice changes in the patient’s level of consciousness and a decreasing Glasgow Coma Scale (GCS) score.   

As the condition worsens, the patient may develop seizures as the brain starves for oxygen and struggles under increasing pressure. If the pressure is not relieved, the patient may demonstrate posturing (decerebrate or decorticate) and pupil dilation (may be unilateral) because of brain damage. Eye exams may show papilledema, swelling of the optic disc within the eye (usually bilateral) (5). Patients may have all or few of these signs/symptoms, depending on the cause of their increased ICP, their ability to compensate, treatment, severity, and age. Infants may have bulging fontanels since the skull has not fully formed and the intracranial pressure has some room to expand.

Conclusion 

Since the early signs of increased ICP can look like many other things, it is important that the nurse be aware of the patient’s risk for increased ICP based on their injury, surgery, or labs. Being aware of your patient’s risks can help you differentiate between a headache caused by lack of caffeine, for example, versus increasing ICP. A patient being seen for an appendectomy or tonsillectomy may not be as concerning as a patient with meningitis, metastatic cancer, or motor vehicle accident. The best bet is to perform regular and consistent neuro exams and pay attention to changes since you could be the one to notice subtle declines before they are fatal.  

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