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Peds Exam 2
Neuro Disorders Day 2
| Question | Answer |
|---|---|
| Traumatic Brain Injury (TBI) are the | Leading cause of death and disability in children 1-19 years boys 2x more than girls MVA are the leading cause of death |
| MVA are the leading cause of death but | if car seat is used properly, decreases the risk of injury 70-80% and risk of death by 28% |
| Injury related to | force of impact |
| GCS < 8 = | severe brain injury |
| GCS is | the golden standard, highest score is 15 |
| closed injury | no break in skull, causes by rapid accelerations/decelerations |
| penetrating injury | break in skull/skin, not as common in kids |
| Closed Head Injury types | Direct - focal Indirect - diffuse Primary Secondary |
| Direct - focal | Force directly impacts the head - trauma, skull break, bleeding |
| Indirect - diffuse | Compression and rebounding of the brain- acceleration/deceleration Diffuse axonal injury responsible for loss of consciousness, coma |
| Diffuse axonal injury responsible for loss of consciousness, coma because | can tear axons/nerves comas are kids not responding to brain bleeds |
| primary | direct hit, neuro could fix this coup! |
| secondary | causes most morbidity cascades after that cause the diffuse generalized swelling, 24-72hrs and kids have hyperemia which increases blood flow contrecoup! |
| Concussions are | all different |
| Concussions are the | Most common traumatic brain injury more common in women who have smaller necks |
| concussion mechanisms | acel/decel |
| concussions are a | Functional injury, not structural injury |
| a person with a concussion will | have symptoms but imaging looks normal |
| Immediate signs of a concussion | Disorientation or confusion Vomiting Amnesia Loss of consciousness - NOT required |
| Common symptoms of a concussion | Headache Migraine Cognitive problems Dizziness/motion sensitivity Fogginess Nausea or vomiting Fatigue or feeling sluggish Changes in mood Sleeping or trouble sleeping, crying |
| if their is dizziness on the field, | suggests long term recovery |
| Post concussion syndrome | symptoms last > 4 weeks have 3 or more Sx |
| risks for longer recovery | previous concussion previous condition (migraines) younger (10-18yrs) |
| when do most concussions resolve by | 1-3 weeks |
| when in doubt | sit them out! |
| Concussion symptoms young child | Sad mood Easily upset, more temper tantrums Crying more Changes in play or behavior Sleep or eating changes Headache Lack of interest favorite toy Loss of new skill Balance issues, trouble walking Unable to pay attention |
| subtypes of concussions | Cognitive/Fatigue Vestibular Ocular Post-traumatic migraine Cervical Anxiety/ Mood |
| Cognitive/Fatigue | Trouble concentrating, learning, retaining new information |
| Vestibular | Balance issues |
| Ocular | Difficulty with tracking |
| Post-traumatic migraine | Headache, nausea, light sensitivity |
| Anxiety/ Mood | Excessive worry |
| Concussion- Diagnosis | Physical exam Interview Neurocognitive tests (impact testing) Vestibular ocular motor screening Imaging |
| Concussion Evidence Based Management | Physical and Cognitive rest- acute injury Active treatment approach Neurocognitive testing Athlete remove from play until medically cleared |
| Physical and Cognitive rest- acute injury | Step by step return, if they have Sx then STOP!! |
| Active treatment approach | Vestibular therapy Vision therapy Exertion therapy Medications |
| Athlete remove from play until medically cleared | Risk- Second impact syndrome Monitor very close |
| Skull Fractures | Linear Comminuted Depressed - Possible emergent surgery Open Basilar |
| linear | one break, asymptomatic, heals spontaneously in 3-4 months |
| communited | multiple breaks |
| depressed | emergency because pushing on brain and will need to be elevated emergent surgery is dependent on degree pressed in |
| open | skin is open |
| basilar | skull fracture, very serious because close proximity to brainstem difficult to diagnose |
| basilar signs | Battle sign - develops after, bruising behind ear Raccoon eyes - 2 black eyes CSF leak - from ear to nose |
| CSF leak in basilar fracture | clear not cloudy but if it drips on white gauze or linen, it looks yellow blood in the middle |
| difference btwn CSF and nasal secretions | CSF has glucose Nasal secretions have no glucose |
| skull fractures in infants | require a significant amount of force to happen so very uncommon in younger than 2 years |
| Hemorrhages and Hematomas | hemorrhages are more severe hematomas are bruising so they're milder |
| Epidural-between skull and dura | Associated with linear skull fracture Arterial Loss of consciousness, followed by normal period, then lethargy or coma One enlarged pupil Vomiting |
| only epidural space if | bleeding into it, often meningeal artery ruptured so needs to be treated immediately and decompensated quickly |
| one enlarged pupil in epidural H and H because | epidural space is pushing into the brain kids do much better because the bleeds can't cross suture signs |
| Subdural -between dura and arachnoid space | Venous (acute or chronic) Common infants with non- accidental trauma Infant high mortality -diffuse injury |
| subdural: Venous (acute or chronic) | tearing of bridging veins |
| subdural have | Infant high mortality -diffuse injury because spreads thin and involves large portion and crosses sutures |
| acute venous subdural | present cardiac arrest or seizing |
| chronic venous subdural | pediatric office, jump in OTC |
| subdurals are | much more common and a vulnerable area for increase in ICP |
| Abusive Head Trauma (Shaken Baby Syndrome) | Non-Accidental Trauma (NAT) Subdural hematoma/hemorrhage bc tear in bridging veins Retinal hemorrhages bc tear in brain Story inconsistent with injury |
| associated findings in abusive head trauma | Skeletal survey positive for fractures (ribs bc hold too tight) Bruising different stages (in areas where they shouldn't be) |
| what should you do when suspect Abusive Head Trauma (Shaken Baby Syndrome) | observe parent/child interaction |
| Clinical Manifestations-TBI minor injury | Possible loss of consciousness Transient confusion Somnolence Listlessness Irritability Pallor |
| Clinical Manifestations-TBI signs of progression | Altered mental status Increased agitation Focal neurologic deficits Emesis Changes in vitals |
| Clinical Manifestations-TBI severe injury | Signs of increased ICP |
| Diagnostic Tests- TBI | CT (quickly done in ER) and/or MRI Cervical spine x-rays bc risk of SCIWORA EEG- to detect seizures |
| Cerebral Hemodynamics of severe brain injury: Cerebral Perfusion Pressure “CPP” | MAP – ICP= CPP Maintain > 60 Parameters may be adjusted for child’s age |
| what increases risk in mortality in TBI | hypotension |
| Cerebral Hemodynamics of severe brain injury: ICP | Normally 5-15 TBI patients- goal ICP < 20 |
| Severe Brain Injury Management: surgical | OR for evacuation of blood / tissue- craniotomy External Ventricular Drain (EVD) ICP monitoring Licox monitor Craniectomy with duraplasty and possible lobectomy |
| External Ventricular Drain (EVD) | Diverts flow of CSF externally - allows brain to swell more Flow rate determined by level above midbrain (tragus of ear) |
| Licox monitor | tissue oxygen stats |
| Craniectomy with duraplasty and possible lobectomy | removal of piece of skull to allow for swelling to expand and replace skull after swelling resolves |
| Severe Brain Injury Management: medical | NPO Hypothermia therapy Hypertonic Saline therapy (3% NS) Mannitol Sedation & Paralytics Pentobarbital Coma Controlled Ventilation & PaCO2 Antiepileptics Antibiotic therapy Adrenocorticosteroids - NO role after TBI |
| Sedation & Paralytics | After immediate neuro assessment completed |
| Hypothermia therapy | don't want fever so we wan't a normal temp or even a lower one |
| Hypertonic Saline therapy (3% NS) | hyperosmolar therapy pulls fluid from brain into the intravenous space |
| Mannitol | could drop BP, IV push in emergency |
| Controlled Ventilation & PaCO2 | increased CO2 is a potent vasodilation so increase in swelling and ICP so we want CO2 to be decreased or normal |
| antiepileptics are used | prophylactically |
| TBI and Na | we never want Na low, we always want it high |
| nursing care assessment for TBI | Monitor LOC and signs of increased ICP Monitor vitals Check for CSF drainage from ear and nose Serum sodium Urine output |
| nursing care interventions for TBI pt 1 | Maintain adequate: Ventilation Oxygenation Circulation Electrolyte balance, (Na) |
| nursing care interventions for TBI pt 2 | Elevate HOB 30 degrees Keep head in neutral position Maintain spine precautions (cervical collar) until cleared Avoid activities that increase ICP Nutrition Provide support to child/family Collaborate with PT/OT Rehabilitation |
| Maintain spine precautions (cervical collar) until cleared | Risk for SCIWORA |
| Nutrition | May have swallowing issues |
| Collaborate with PT/OT | Splints- prevent contractures Helmet when OOB if craniectomy until skull piece is replaced |
| Keep head in neutral position | neutral to promote drainage |
| Sequela Traumatic Brain Injury | Postconcussion syndrome Posttraumatic headaches Posttraumatic seizures- higher risk in children Hydrocephalus |
| Physical Developmental Implications | sensory impairments fine and/or gross motor deficits balance/coordination language deficits |
| Cognitive Developmental Implications | memory loss, confusion, inattention, difficulty concentrating, diminished abstract reasoning significant cognitive delays language deficits |
| Social Developmental Implications | aggression/anti-social behaviors impaired adaptive behaviors diminished confidence/self-worth |
| Head Injury Prevention Strategies | Safety gates stairs (top and bottom) Top bunk bed contraindicated <6 years-old Proper seatbelt and car seat use Helmet use during recreational activities Preventing child abuse - never shake a baby |
| seizures are | Uncontrolled electrical discharge of brain neurons: imbalance between excitatory and inhibitory neurons Individual event!! does NOT mean epilepsy |
| Uncontrolled electrical discharge of brain neurons | Hyperexcitable neurons: Na, K, Ca, and Cl- ion channels Suppressed inhibitory mechanisms: Gamma-aminobutyric acid (GABA) |
| causes of seizure | Idiopathic, fever, intracranial infection/lesion/hemorrhage, cerebral edema, toxins, lead poisoning, metabolic disorder, brain malformations, genetic disorders, toxin ingestion |
| epilepsy is a | Disorder – recurrent seizures |
| diagnosis requirements for epilepsy | >2 unprovoked seizures > 24 hours apart 1 unprovoked seizure within 10 years of 2 unprovoked seizures |
| Highest incidence of epilepsy | early infancy |
| cause of epilepsy in infants | congenital brain malformations, genetic disorders |
| cause of epilepsy in children | idiopathic, infection |
| risks for epilepsy | trauma, hemorrhage, anoxia, toxins, hypoglycemic injury, uremia, migraine, cardiovascular dysfunction |
| presentation of epilepsy in younger than 6 | less complex behaviors, more subtle |
| presentation of epilepsy in older than 6 | like adults |
| Classification of Seizures are based on | where seizure begins level of awareness features |
| classifications of seizures | Focal- restricted to 1 side of brain Generalized- involves both sides at onset Focal to generalized - starts on 1 side, spreads to both |
| level of awareness | Focal aware (simple) or Focal impaired awareness (complex) Generalized- awareness always affected |
| Features | Motor symptoms, somatosensory, psychic, autonomic, combination |
| focal seizure | KNOW restricted to 1 side of brain, motor and moving 1 side |
| generalized seizure | KNOW involves both sides at onset, moving both sides |
| focal to generalized | starts on 1 side, spreads to both can start with thumb |
| Focal aware (simple) | can't speak but know whats going on |
| Focal impaired awareness (complex) | can't recall entire thing |
| Generalized | awareness always affected |
| Focal (Partial) Seizures Awareness | Impaired (complex) or Intact (simple) |
| Focal (Partial) Seizures Focal Motor | Twitching, jerking, stiffening movement, automatisms (coordinated mvmt but non purposeful), turning of eyes, head and or trunk |
| Focal (Partial) Seizures focal non motor (sensory) | sensation, emotion, smell, taste, vocalization or arrest of speech |
| Focal (Partial) Seizures Aura | Sensation at start of seizure - PART OF SEIZURE Focal to generalized seizures Infants may cry |
| what should you ask when you have a patient with seizures | what do they do during their seizures |
| generalized seizures affect | both sides |
| generalized seizures awareness | altered |
| generalized seizures have | no warning, no aura |
| generalized motor seizure - bilateral | Atonic Myoclonic Tonic Generalized tonic clonic |
| generalized non motor seizure | absence |
| absence seizures | "zone out" if they respond to you when they're touched, not a seizure |
| previous names for absence seizure | petit mal |
| absence seizures awareness | Brief lack of awareness (5-10 seconds) Minimal alterations in muscle tone Mimics daydreaming or inattention (not doing well in school) Hyperventilation precipitating factor |
| absence seizures can happen | more than 100 times a day, basically just staring off |
| absence seizures normally happen when | 5-8 years and stop at puberty |
| Atonic Seizure | Drop Attack (drop forward) Loss of muscle tone and posture control Typically fall forward May Cause Injury |
| Atonic Seizure happen when | 2-5 years |
| Myoclonic Seizure | Sudden, brief contractures of muscles - jerk, startle movement MYO- muscle CLONUS- Movement Focal or generalized onset May or may not have a lack of awareness May be benign or occur with other seizure disorders |
| Tonic Clonic Seizure | Immediate & complete LOC Generalized 3 phases |
| 3 phases of tonic clonic seizure | Tonic (10-30 seconds) Clonic Post-ictal |
| 1. Tonic (10-30 seconds) | Increase tone, may bite tongue - extend out and everything stiffens Apnea possible |
| 2. Clonic | Rhythmic repetitive jerking Incontinence possible Starts strong- decreases gradually |
| 3. Post ictal | lethargic, headache possible, don't remember sleep for hours |
| pseudoseizures are | psych condition |
| Febrile Seizures are | (generalized) Tonic/clonic seizure associated with fever |
| Febrile Seizures are associated with | infectious processes - roseala or URI |
| Febrile Seizures happen when there is a | positive family history |
| Febrile Seizures occur most often at | 6 months and 5 years of age |
| Febrile Seizures can be | singular or repeated simple or complex |
| Febrile Seizures are generally | a one time event DO NOT mean epilepsy |
| Febrile Seizures are treated with | fever meds, NOT seizure meds |
| Status Epilepticus | Continuous seizure lasting > 5 minutes Series of seizures without regaining consciousness |
| Status Epilepticus: emergency | Maintain airway and oxygenation IV anti-epileptic agents - also rectal, nasal (home use) |
| for Status Epilepticus patients, | ALWAYS have IV access |
| as a nurse with a patient with seizures, | time the seizures! |
| Infantile Spasms (West syndrome) | Epileptic disorder resulting from known or suspected central nervous system malformation |
| Infantile Spasms (West syndrome) affects | children < 1 year of age- avg onset 4 months |
| Infantile Spasms (West syndrome) has a strong association with | developmental delay or regression |
| Infantile Spasms (West syndrome) have a series of | Series of sudden, brief, symmetric muscular contraction: Head flexed, arms extended, legs drawn up Eyes may roll upward or inward |
| a patient with Infantile Spasms (West syndrome) on EEGs | Hypsarrhythmia's on EEG |
| treatment for Infantile Spasms (West syndrome) | ACTH |
| Diagnosis of Seizures | history physical exam |
| physical exam to diagnose seizures | Labs- complete blood count, glucose Toxicology screen Lumbar puncture CT/MRI Electroencephalogram (EEG) |
| what determines cause and not diagnosis of seizures | Labs- complete blood count, glucose Toxicology screen Lumbar puncture CT/MRI |
| what determines diagnosis and not cause of seizures | EEGs and history |
| Management During Seizure: #1 priority | airway! |
| Management During Seizure: Airway #1 priority | Open-jaw thrust Clear- Position on side: so increase salivation and vomit comes out Oxygen Don’t put anything in patient’s mouth NPO |
| Management During Seizure: safety | Padded crib or siderails If standing, ease to floor, remove surrounding objects Protect pt from environment Do Not Restrain |
| Management During Seizure: observation | Activity before, during (ictal), afterwards (postictal) Duration |
| seizure precautions | pads oxygen suction |
| Management of Seizure Disorders | Control the seizures - completely, or reduce frequency and severity Correct underlying cause(s) Identify and control triggers (avoid) Maximize normalcy and optimal development |
| Maximize normalcy and optimal development of seizure disorders | educational deficits may result from chronic or poorly controlled seizures stigmatizing condition |
| Drug Therapy- Seizure Disorders | Anti-epileptic drugs raise seizure threshold Dosing and combinations of drugs Monitor therapeutic levels - serum Discontinuation protocols |
| Anti-epileptic drugs raise seizure threshold | you inherit seizure threshold |
| Dosing and combinations of drugs | maximize seizure control minimizing side effects |
| Monitor therapeutic levels - serum | not at the time of tonic/clonic |
| Discontinuation protocols | > 2 years seizure-free, normal EEG gradual withdrawal- wean slowly |
| contractable epilepsy | if on two or more meds and still having seizures |
| Refractory Seizures: vagus nerve stimulator to | decrease amount of seizures |
| what are vagus nerve stimulator | surgically implanted device Stimulation to brain from vagus nerve: regular intervals (every so often), hand-held magnet (parents swipe over their chest to send additional impulses) |
| Refractory Seizures: surgery | track pathway of seizures and remove it corpus callostomy: separate R&L hemispheres so just focal and not generalized if super bad: lobectomy (remove a lobe) |
| Refractory Seizures: ketogenic diet | limits carbohydrates, high fat Ketosis - anticonvulsive effect can help with seizures |
| intractable seizures | difficult to treat, already at max of 2 meds |
| responsive neuro stimulation | leads to measure waveforms learn childs normal waveforms to send transmissions as abnormal waves go off |
| breath holding can be confused with | seizures |
| breath holding is when | Child involuntarily stops breathing, brain becomes anoxic, cyanosis may develop, may lose consciousness |
| breath holding can cause | Possible change in muscle tone, seizure like activity, hypoxic convulsions, last 30-60 seconds |
| breath holding resolves | spontaneously: may cry, scream, try to catch breath once regain consciousness |
| breath holding types | Cyanotic- from anger, frustration Pallid- from being startled or pain |
| Cyanotic breath holding- from anger, frustration | crying, tantrum, not intentional, turn blue |
| Pallid breath holding- from being startled or pain | turn pale, short lived |
| breath holding will outgrow without | treatment, 6mo-6yo and will outgrow btwn 4-8yo |
| breath holding is aggravated by | iron deficiency |
| Breath Holding Evaluation | Evaluation first spell |
| Breath Holding educate and support family: during spell | Lay child down, protect from environment, stay with child If becomes unconscious, check mouth for food or object Call 911 if lasts > 1 minute |
| Breath Holding educate and support family: after spell | Reassure child Spell is involuntary |
| Breath Holding educate and support family: prevention | Iron if deficiency Calm discipline methods Provide structure and consistency Prevent from getting overly tired or hungry |
Created by:
leh195