Exam 11: Cerebral Dysfunction in the Pediatric Patient
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| Cerebral Dysfunction: Types of measurement | i. Newborn health and brain status
ii. Intellectual disability
iii. Hypoxic injury
iv. Developmental milestones
v. Level of consciousness
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| Refelexive | Early neurologic responses in infants are primarily
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| Increased Intracranial Pressure (ICP) | any increase in the three components located in the cranium that increases the total volume to greater than 100%.
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| cranium’s total volume | made up of 80% brain, 10% cerebrospinal fluid (CSF), and 10% blood.
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| How does the body compensates to keep the total volumes equal? | i. Reduced blood volume
ii. Decrease in CSF production
iii. Increase in CSF absorption
iv. Brain mass shrinkage by displacement of intracellular and extracellular fluid
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| How do children with open fontanels compensate? | skull expansion and widened sutures
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| Altered States of Consciousness | Any change in the ability to respond to sensory stimuli and have subjective experiences (consciousness—awareness)
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| Components of Consciousness | Alertness.
Cognitive power.
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| Alertness | an arousal-waking state, includes the ability to respond to stimuli
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| Cognitive Power | the ability to process stimuli and produce verbal and motor responses
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| Unconciousness | depressed cerebral function
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| purpose of the neurological examination | establish an accurate, objective baseline of neurologic information.
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| Body temperature is often elevated and may be extreme | i. Acute infectious process
ii. Heat stroke
iii. Ingestion of drugs
iv. Intracranial bleeding
v. Hypothalamic involvement (increased/decreased)
vi. Coma from toxic ingestion may produce hypothermia
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| Hyperventilation is usually a result | metabolic acidosis or abnormal stimulation of the respiratory center of the brain.
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| Periodic or irregular breathing is an ominous sign of | brainstem dysfunction that often precedes complete apnea.
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| neurosurgical emergency | The sudden appearance of fixed and dilated pupil(s)
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| Dilated and fixed pupils suggest | paralysis of cranial nerve III secondary to pressure from herniation of the brain through the cranium, hypothermia, anorexia, ischemia, poisoning with atropine-like substances, mydriatic drugs.
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| Pinpoint pupils are commonly observed in | poisoning (opiate, barbiturate) or in brainstem dysfunction.
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| Widely dilated and reactive pupils are often seen | after seizures or eye trauma and may be only one side.
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| Unilateral fixed pupil suggests | a lesion on the same side
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| If pupils fixed bilaterally for more than 5 minutes | brainstem damage is usually implied.
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| Caloric Test or Oculovestibular response is elicited | the child’s head elevated 30 degrees.
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| Papilledema characterized by | i. optic disc edema
ii. indistinct optic disc margins,
iii. hemorrhage
iv. tortuosity of vessels
v. absence of venous pulsations
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| Flexion posturing signifies severe dysfunction of the cerebral cortex. | a. Rigid flexion, arms held tightly to body
b. Flexed elbows, wrists, and fingers
c. Plantar flexed feet
d. Legs extended and internally rotated
e. Possible presence of fine tremors or intense stiffness
f. Also known as decorticate posturing
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| Extension posturing is a sign of dysfunction at the level of the midbrain or lesions to the brainstem. | a. Rigid extension and pronation of the arms and legs
b. Flexed wrists and fingers
c. Clenched jaw
d. Extended neck
e. Possibly arched back
f. Also known as decerebrate posturing
g. Cerebral dysfunction more severe than flexion posturing
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| absent in deep coma. | The corneal, pupillary, muscle-stretch, superficial and plantar reflexes tend to be
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| severe brain damage | Absence of corneal reflexes and presence of a tonic neck reflex are associated with
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| What is the Glasgow Coma Scale used for? | It provides an objective measurement of levels of consciousness.
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| Explain what decerebrate positioning is and what it indicates. | Decerebrate positioning is a sign of dysfunction at the midbrain characterized by rigid extension and pronation of the arms and legs. pROGRESION OF NEUROLOGICAL INSULT.
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| Emergency measures of the unconscious child are aimed toward | ensuring a patent airway, treatment of shock, and decreasing ICP (if present).
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| aspiration and cardiac arrest | Dysfunction of cranial nerves IX and X places the child at risk for
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| irreversible brain damage. | Cerebral hypoxia lasting longer than 4 minutes nearly always causes
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| four types of ICP monitors | i. Intraventricular catheter with fibroscopic sensors
ii. Subarachnoid bolt (Richmond screw)
iii. Epidural sensor
iv. Anterior fontanel pressure monitor
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| Indications for inserting an ICP monitor are | i. GCS evaluation of 8
ii. GCS evaluation of less than 8 with respiratory assistance
iii. Deterioration of condition
iv. Subjective judgment regarding clinical appearance and response
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| Nurses caring for patients with intracranial monitoring devices must | i. Be acquainted with system used
ii. Assist with the insertion
iii. Interpret the monitor readings
iv. Be able to distinguish between danger signals and mechanical dysfunction
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| Hyperthermia | usually accompanies cerebral dysfunction
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| The three major causes of brain damage in childhood (in order of importance) | Falls.
MVAs.
Bicycle Accidents.
Big ol heads of infants.
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| Why are falls a major cause of brain damage in childhood? | Because infants are frequently left unattended on beds, in high chairs, and other places from which they can fall. Incomplete motor development contributes to falls at young ages.
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| What age do bicycle injuries occur? | Ages 5 to 19.
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| Who are at a greater risk for head trauma? Girls or boys? Why? | Boys are affected twice as often as girls due to their propensity for greater risk-taking.
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| Most common head injury in children... | Concussion.
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| hallmarks of concussion with children | Confusion and amnesia following head injury
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| coup injury | petechial hemorrhages along the superficial aspects of the brain at the site of impact
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| Contrecoup injury | lesion remote from the site of direct trauma
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| Types of fractures | Linear Fracture.
Depressed Fractures.
Comminuted Fracture.
Basilar Fractures.
Open Fractures.
Diastaic Fractures.
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| Linear fractures | the lines of the fracture are predetermined by the site and velocity of the impact and the strength of the bone. Uncommon before 2-3 years of age but constitute the majority of childhood skull fractures
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| Depressed fractures | bone is locally broken usually into several irregular fragments that are pushed inward causing pressure on the brain. Uncommon before age 2-3 years. Infants & young children, skull may become dented in a peculiar rounded or “ping-pong ball” depression.
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| Comminuted fractures | consists of multiple linear fractures which result from intense impact, may be from repeated blows against an object and may suggest child abuse.
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| Basilar fractures | involve the basilar portion of the frontal, ethmoid, sphenoid, temporal, occipital bones. Because of the proximity of the fracture line to structures surrounding the brainstem, this is a serious head injury.
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| Signs and symptoms of Basilar Fractures | include subcutaneous bleeding in the posterior neck area and over the mastoid process (battle sign), bleeding around the eyes (raccoon eyes), or bleeding behind the tympanic membrane (hemotympanum)
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| Open fractures | communication between the skull and the scalp or the surfaces of the upper respiratory tract such as the paranasal sinuses or middle ear. Increased risk of CNS infection; facial paralysis, vertigo, tinnitus, or hearing loss may develop
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| Diastatic fractures | traumatic separations of the cranial sutures, most frequently affect the lambdoid suture and are rarely seen beyond the first 3 years of life.
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| Complications of head injuries include | Hemorrhage.
Edema.
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| Epidural hemorrhage | Blood accumulates between the dura and the skull to form a hematoma which forces the underlying brain contents downward and inward as the brain expands
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| Subdural Hemorrhage | Blood accumulates between the dura and the cerebrum, usually as a result of rupture of cortical veins that cross over the subdural space. 10x more frequent than epidural hemorrhage.
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| Cerebral edema is caused by | direct injury induces vascular stasis, anoxia and further vasodilatation.
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| Antiepileptics (Head trauma) | used for seizure control and in cases of suspected contusion or laceration.
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| Antibiotics (Head Trauma) | may be administered if there is any chance of infection
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| What are the potential complications of head injuries? | Hemorrhage, infection, cerebral edema and brain herniation.
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| : What nursing intervention is most appropriate for a child with a head injury who is very restless and irritable? | Provide analgesic as ordered
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| Near-drowning (Statistic) | Major cause of accidental death in children of 1 year of age.
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| Near-drowning (definition) | survival at least 24 hours after submersion in a fluid medium.
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| Problems caused by near-drowning | Hypoxia.
Acute Ventilator Insufficiency.
Asphyxiation of fluid.
Hypothermia.
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| For a child admitted for a near drowning, what is the priority nursing consideration? | Respiratory support with attention to vital signs.
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| Brain tumor fact | Brain tumors are the most common solid tumors in children and are the second most common childhood cancer.
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| The majority of brain tumors are | infratentorial which means that they occur in the posterior third of the brain, primarily in the brainstem or cerebellum.
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| Other brain tumors are | supratentorial or within the anterior two thirds of the brain, mainly the cerebrum.
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| Brain tumor: S/S (older children) | Headache, especially on awakening.
Vomiting that is not related to feeding. Occurs due to increased ICP, stimulating the vomiting center in the medulla.
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| Brain Tumor: Diagnostic Tests | An MRI which determines the location and extent of the tumor. Other tests include CT, angiography, EEG, and lumbar puncture.
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| Why is temperature checks post-op brain surgery so important on child? | important because of hyperthermia resulting from surgical intervention in the hypothalamus or brainstem and from some types of general anesthesia.
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| What are the most common signs and symptoms of a child with a brain tumor? | The most common symptoms are: headache, especially on awakening and vomiting that is not related to feeding.
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| A child with a brain tumor is 4 hours postop. There is a small amount of clear drainage noted on her dressing. What do you suspect it is and what is the most appropriate thing for you, the LPN to do immediately? | The presence of colorless drainage is reported immediately because it is most likely CSF from the incision area.
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| Therapeutic Management of Brain Tumor | Surgery (treatment of choice).
Radiation (Used to treat most tumors).
Chemotherapy (keeps tumor at bay).
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| craniosynostosis | a condition in which one or more of the fibrous sutures in an infant skull prematurely fuses by turning into bone (ossification), thereby changing the growth pattern of the skull.
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| Hydrocephalus | condition caused by an imbalance in the production and absorption of CSF in the ventricular system.
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| Nonobstructive or communicating Hydrocephalus | a. impaired absorption of SCF fluid within the subarachnoid space
b. obliteration of the subarachnoid cisterns
c. Malfunction of the arachnoid villi
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| Obstructive or Noncommunicating Hydrocephalus | obstruction to the flow of CSF through the ventricular system
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| What is the most common way that hydrocephalus is diagnosed in infants? | Based on head circumference that crosses on or more gridlines on the growth chart within a period of 2 to 4 weeks.
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| What are the signs and symptoms of infection in a child that is 24 hours postoperative shunt revision? | The signs and symptoms include: elevated vital signs, poor feeding, vomiting, decreased responsiveness, and seizures.
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