cerebral dystunctions in peds
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| General aspects | Delay or deviation from expected milestones helps ID high-risk children. Get pregnancy & delivery history. Family history (genetic), health history (chemicals, trauma, illness), physical exam
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| increased ICP signs in infants | tense or bulging fontanels, separated cranial sutures, irritability, high-pitched cry, inc occipitofrontal circumference, distended scalp vein, setting-sun eyes, changes in feeding habits
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| increased ICP signs in children | Babinski after age 2, HA, N/V, diplopia (blurred vision), seizures, decline in school performance, increased sleeping, memory loss, inability to follow simple commands, diminished physical activity
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| Late signs of ICP | bradycardia, dec LOC, dec motor response to commands, dec sensory response to painful stimuli, alterations in pupil size and reactivity, flexion or extension posturing, Cheyne-Stokes respiration, Coma
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| Increased ICP | Anything that puts pressure on intracranial space. Caused by trauma (shaken baby), hydrocephalus, viral/bacterial infection, tumor, electrolyte imbalance (cerebral edema with increased Na) structural defect.
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| Level of consciousness | full:awake, alert, orientated. confused:impaired decision making. Disorientation: to time/place. Lethargy:sluggish speech. Obtundation:arouse w/ stimu. Stupor:respond to vigorous stimu. Coma:no motor response to stimulation. Persistent vegetative state
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| Glascow scale | 3 part assessment. Eyes, verbal response, motor response. Score of 15 is unaltered LOC, score of 3 is worst score on scale.
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| Eyes | pinpoint pupils-poisoning or brainstem dysfunction. widely dilated & reactive seen after seizures (may involve only 1 side). Widely dilated & fixed suggest cranial nerve III paralysis from brain hernia. Pupils fixed bilaterally >5 min is brainstem damage
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| Motor Functions | look for spontaneous activity, response to painful stimuli for clues on location & extent of cerebral dysfunction. Asymmetric movements of limbs can be paralysis. Hemiplegia:affected limb will fall uncontrollably when lifted & dropped.
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| decorticate posturing | severe cerebral cortex dysfunction characterized by adduction of the arms at the shoulders, flexion of the arms on the chest with wrists flexed and hands fisted, and extension and adduction of the lower extremities
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| Decerebrate posturing | sign of dysfunction at the level of midbrain; characterized by rigid extension and pronation of the arms and legs; may not be evident when child is quiet, but can be elicited by applying painful stimuli such as pressure on the base of the nail
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| Reflexes | corneal, pupillary, muscle-stretch, superficial and plantar reflexes tend to be absent in deep coma. Absence of corneal reflexes and presence of tonic next reflex are associated with severe brain damage. Babinski if found in children older than 18 months.
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| Diagnostic procedures | Labs for glucose, CBC, electrolyte, blood culture. Imaging: CT, MRI, emission tomography. Spinal tap for pressure and meningitis
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| Nursing care of an unconscious child | Pain: inc ICP, HR, RR, BP & dec O2 saturation. Pain indicated by inc agitation in a comatose child. Turn of lights and elevate HOB. Opioids, fentanyl, midazolam, acetaminophen and codeine. Risk of aspiration of secretions is high, suctioning will inc ICP.
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| Emergency treatment of an unconscious child | airway, reduction of ICP, treat shock. Airway always #1!
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| ICP monitoring | Glascow scale evaluation of 8 or <8 with resp assistance. Subjective judgment. A catheter allows for continuous drainage to dec pressure. Monitor carefully. If draining to low improper CSF decompression can occur. If too fast can cause bleeding and pain.
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| Nursing care of a child with ICP | side-lying with elevated HOB, small firm pillow under head. Upper limbs are flexed and supported by pillows. Footboards help prevent foot drop. Exercise should be ROM to prevent contractures of joints.speak to unconscious child like any other child
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| Nutrition and hydration of ICP child | IV administration and parenteral nutrition, caution with overhydration. Later begin gastric feedings via NG tube.
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| altered pituitary secretions | syndrome of inappropriate antidiuretic hormone and diabetes insipidus may go with CNS disease. Resulting from hypothalamic dysfunction. Treat with fluid replacement, electrolyte balance and medications.
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| Cerebral trauma | head injury from falls, MVA, bicycle injuries. Vulnerable to acceleration-deceleration injury due to larger heads and insufficient musculoskeletal support. Primary injuries are skull fracture, contusions, intracranial hematoma and diffuse injury.
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| Cerebral hyperemia | diffuse generalized cerebral swelling produced by increased blood volume or redistribution of cerebral blood volume. occurs more often in children then adults because of volume expansion causing intracranial hypertension
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| Prognosis of cerebral trauma in children | children have a higher percentage of good outcomes, lower mortality rate and lower incidence of surgical mass lesions after a severe head trauma. Their thinner, softer skill may sustain greater long-term damage than adults.
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| complications of cerebral trauma | hypoxic brain injury, increased ICP, infection and cerebral edema
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| concussion | most common. Transient and reversible from trauma to the head causing instantaneous loss of awareness and responsiveness lasting for minutes to hours followed by amnesia and confusion
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| Contusion and lacerations | term used to describe visible bruising and tearing of cerebral tissue. Coup is bruising at point of impact and Contrecoup is bruising at site far removed from point of impact
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| Skull fractures | linear & depression uncommon before 2-3 years. Comminuted suggest child abuse. basilar* severe, 80% of cases have subcutaneous bleeding in neck & eyes (raccoon), diastatic- rare after 3 years, growing- infants w/ isolated fracture check 1-2mo after injury
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| epidural hemorrhage | less common in children because the middle meningeal artery isn’t embedded in the bone surface of the skull until age 2.
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| Subdural hemorrhage | bleeding between the dura and cerebrum, 10x more frequent them epidural hemorrhage occurs most often in infancy with peaks at 6 months. Children with subdural and retinal hemorrhages should be evaluated for child abuse (shaken baby)
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| Emergency head injury care | ABC, keep NPO, assess pain but dont give analgesics, check pupils q4h for 48hr, awaken twice at night to check LOC. If child loses consciousness or vomits more than three times, falls from a height greater than childs height get medical attention.
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| Neuroblastoma | most common malignant extracranial tumor in children, most on adrenal gland or retroperitoneal sympathetic chain. S/S depends on stage & location. IV pyelogram for renal involvement. Surgical removal, bone marrow transplant, stem cell
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| Neuroblastoma prognosis | 88-90% survival at 5 y for low risk, 22-30% survival at 5 years for high risk. Younger at diagnosis is better prognosis. May have spontaneous regression a embryonic cells mature and with development of active immune system
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| Bacterial meningitis | acute inflammation of meninges & CSF. Caused by streptococcus pneumonia & group B streptococci. Droplet infection from nasopharyngeal. Appears as extension of a bacterial infection through dissemination then spreads through CSF.
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| bacterial meningitis treatment | diagnosed by spinal tap.S/S: abrupt onset, fever, chills, HA, vomiting, seizures, pos Brudzinski signs. isolation precautions, antimicrobial therapy, maintain hydration, ventilation & control seizures and temperature. decrease incidence with “Hib” vaccine
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| nonbacterial (aseptic) meningitis | mainly from viruses, may be associated with measles, mumps, herpes & leukemia. Onset is gradual or abrupt. HA, fever and malaise. Treatment is primarily symptomatic, until definitive diagnosis is made antimicrobials administered and placed in isolation.
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| Encephalitis | inflammatory process of CNS with altered function of brain & spinal cord, caused by variety of organisms, mainly viruses. Mosquitos & ticks, measels, mumps. S/S: malaise, fever, stiff neck, N/V, ataxia. Severe: high fever, seizures, coma, paralysis.
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| Management of encephalitis | hospitalized for observation and support. Control of cerebral manifestations, adequate nutrition and hydration. Cerebral hyperemia occurs in severe viral encephalitis and ICP monitoring. Prognosis depends on age, type and residual neurologic damage
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| Rabies | acute infection of the NS by a virus that is fatal if left untreated. Transmitted to humans by an infected mamma. 12% of cases from domestic animals. S/S: general malaise, fever, sore throat, hypersensitivity, seizures, chocking, apnea, cyanosis, anoxia
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| Reye's syndrome | : toxic encephalopathy associated with other characteristic organ involvement. Fever, profoundly impaired consciousness and disordered hepatic function. Most cases after influenza, varicella, aspirin therapy fever and development of RS
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| stages of reye's syndrome I-III | I: vomiting, lethargy, liver dysfunction, pupil reaction brisk. II: disorientation, delirium, liver dysfunction, pupil reaction sluggish. III: obtunded, coma, hyperventilation.
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| stages of reye's syndrome IV-V | IV: deepening coma, decerebrated rigidity,evidence of brainstem dysfunction.V: seizures, loss of deep tendon reflexes, respiratory arrest, usually no evidence of liver dysfunction
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| Treatment | liver biopsy is diagnosis. Early diagnosis & aggressive therapy. Cerebral edema with inc ICP is most immediate threat to life, 1/3 of patients causes death or long term neurologic sequelae. Care is that of any ICP and altered state of consciousness
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| Seizure Disorders | malfunction of electrical system of the brain. Determined by site of origin. Most common neurologic dysfunction in children. Class: partial- local onset w/ small location of brain. Generalized- involves both hemispheres without local onset. unclassified.
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| Epilepsy | : two or more unprovoked seizures and can be caused by variety of pathologic processes in the brain. Optimal treatment and prognosis requires an accurate diagnosis and determination of cause
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| Etiology of seizures | acute symptomatic: associated with head trauma or meningitis. Remote symptomatic: prior brain injury such as encephalitis or stroke. Cryptogenic: no clear cause. Idiopathic: genetic in origin
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| Therapeutic management of seizures | control seizures by reducing frequency and severity. Discover and correct cause. Drug therapy, ketogenic diet, vagus nerve stimulation, epilepsy surgery. Figure out the triggering factors, goal is for child to live as normal a life as possible
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| Absence seizures | called petit mal or lapses, brief loss of consciousness, minimal or no change in muscle tone. Almost always appear in childhood (4-12)
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| Atonic seizures | : sudden momentary loss of muscle tone (drop attacks) onset age 2-5. May or may not have loss of consciousness, sudden fall to ground, often on face. Less severe: head droops forward several times.
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| Myoclonic seizures | sudden brief contractions of muscle groups, may be single or repetitive, no loss of consciousness. Often occur when falling asleep. May be nonspecific symptom in many CNS disorders. May be mistaken as exaggerated startle reflex.
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| infantile seizure | onset in first 6-8 months, usually associated with some degree of cognitive impairement. Caused by disturbance in central neurotransmitter regulator at specific phase of brain development
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| Febrile seizure | transient disorder of childhood affecting 4-8%. 6mo and 3 years. Rare after age 5. Twice as frequent in males. Seizure induced by fever and that is it the peak temperature that is important, not the rapidity of the temperature elevation
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| pharmacologic management of seizures | : monitor therapeutic levels and increase dosage as child ages. Monitor for SE, avoid abrupt discontinuation; gradual dose reduction.
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| Home management of seizures | CPR training for ALL family members, rectal restriction on individual basis. Safety devises (helmets, awareness of school, no swimming alone)
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| Hydrocephalus | caused by imbalance in production & absorption of CSF. Result of developmental abnormalities, apparent in early infancy, other causes neoplasm, infection & trauma. Treatment is relief, complications, problems related to the effects of motor development.
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| Hydrocephalus treatment | often surgical w/ ventriculoperitoneal shunt. look for; kinking, plugging, separation or migration of tubing. Shunt infection greatest 1-2mo after placement. Infections include septicemia, bacterial endocarditis, meningitis, wound infection.
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