Cerebral Dysfunction Flashcards
1
Q
Neuro diff in kids
A
- greatest brain changes occur in first year of life
- childhood development directly related to brain growth and dev
- brain volume reflected in head size
- cerebral BF and oxygen consumption 2x adult needs
- progressive myelinization=progressive motor fxn
2
Q
Why do kids respond differently to brain injury or disease?
A
- expandable skull since brain not fully fused (fontanelles open)
- greater blood volume in brain
- BBB more permeable (more sus to brain infx tho)
- small epidural space=fewer epidural hemorrhages (other hemorrhage sites are common)
3
Q
Neuro assessment of kids
A
- hx—delivery, APGAR, fall/trauma, exposure, febrile, animal bite, onset, chronic illness
- observation—cry, lethargic, irritable, drowsy, LOC
- HEENT—head circumference under 2Y, fontanelles, pupils, EMV (GCS)
- Respiratory
- VS—esp BP or HR
- GI—gag reflex, emesis (may indicate inc ICP or HA)
- GU—lose incontinence (can happen with sz)
- skin—rash, thermoregulation (occurs with head injury)
- musculoskeletal activity—reflexes, gait, muscle strength, presence of reflexes (esp persistent), posturing
4
Q
Decorticate posturing
A
Curled inward
5
Q
Decerebrate posturing
A
Turned outward
6
Q
Pediatric GCS (don’t need to memorize)
A
Based on child’s age
- Eye opening
- Motor response
- Verbal repsonse
7
Q
Fixed pupils
A
Very dilated pupils indicating brain stem damage if lingers past 5 minutes, hypothermia, poisoning
8
Q
Ptosis
A
Drooping eyelid
9
Q
Increased intracranial pressure
A
Rise in pressure around the brain
- in cranium, CSF 10%, blood 10%, brain 80%
- inc in one means Dec in another or ICP rises
- caused by tumor/lesion, hemorrhage, edema of cerebral tissue, accumulation of CSF
10
Q
S/S inc ICP in kids
A
- nausea/forceful vom
- lethargy, inc sleeping
- declining school performance
- declining motor fxn (clumsier)
- HA
- blurred vision
- see double
- sz
- pupils sluggish to light
11
Q
S/s inc ICP in infants
A
- tense, bulging fontanelles
- separated cranial sutures
- high pitched cry, catlike
- irritable—especially when picked up
- inc head circumference
- poorer feeding
- sun setting eyes—pupils down and sclera is visible above
- taut, shiny skin on scalp
- Late sign—Macewen (cracked pot sound) when knock on skull
12
Q
Later signs of inc ICP
A
- significant Dec in LOC
- Dec motor response to commands
- Dec sensory response to pain
- fixed and dilated pupils
- posturing
- irregular respirations
- very late sign—Cushing’s triad—inc systolic BP, HR and RR go down, widening pulse pressure
13
Q
NC for unconscious kids
A
- Emergent—ensure ABCs, stabilize spine if head injury suspected, treat shock (decreasing BP), Dec ICP
- Ongoing—frequent neuro, LOC, pupillary rxn, VS, pain management q1h
- Pain—inc HR, grimacing, moving around
- resp monitoring
- monitor ICP
- nutrition and hydration
- elimination
- thermoregulation
- positioning
- hygiene—bath
- meds
- stimulation—kept low and quiet, bed not rocked
- family support—nothing definitive with head injuries
14
Q
Hydrocephalus
A
Excessive CSF in ventricular system
- mimics s/s of inc ICP
- inc head circumference
15
Q
Hydrocephalus etiologies
A
- congenital or acquired
- communicating or non communicating
- communicating—CSF due to impaired abs in the subarachnoid space
- noncommunicating—accum due to blockage in ventricles
16
Q
Hydrocephalus management
A
- shunt or drain to pull fluid off
- if think cause if temporary, can do drainage with lumbar puncture
- treat the cause—infx, tumor, lifelong shunt bc defective formation
- treat complications—treat inc ICP mainly, monitor in ICU, supportive
- promote psychomotor dev—will have prob with crawl, head lag
17
Q
Ventricular peritoneal (VP) shunt
A
- drains from ventricular sys to peritoneal cavity
- preferred
- end is coiled in belly which allows child to grow while it uncoils
18
Q
Ventriculoatrial (VA) shunt
A
- runs frm ventricular sys to right atrium
- used in older kids who are mostly grown or kids who can’t use peritoneal cavity
19
Q
Shunt NC
A
- shunt revision is common
- preop–prevent b/d of scalp, infx, monitor for inc ICP, promote adequate nutrition, keep eyes moist, prepare child
- postop–bed rest with minimal handling, lay FLAT on side opposite the shunted side (prevents HA), monitor VS, neuro signs, ab distention, s/s infx, comfort measures, d/c teaching, record dev
20
Q
Shunt NC
A
- teach how to pump the shunt–button on shunt they can press in to relieve ICP–call HCP first
- signs of shunt malfxn–HA, loss of appetite, s/s of ICP, GCS dec,
- avoid contact sports
- never enter military
21
Q
Shunt complications
A
- device removed, external ventricular drain inserted
- drainage bag should be at level of the ear
- close monitoring of EVD
- IV abx for several weeks
- new shunt placed when CSF clear of infx
- new shunt insertion via surgery due to growth, tubing disconnect, kinks
22
Q
Types of EVD for ICP monitoring
A
- intraventricular catheter (drain ICP or use as ICP monitor)
- subarachnoid bolt (Richmond screw)–placed in space right over brain–surgery handles dressing and screw adjustment
- epidural sensor (btwn dura and skull)
- anterior fontanelle pressure monitor–noninvasive and can be slightly inaccurate
23
Q
EVDs NC
A
- keep midline–turning side to side can inc ICP
- keep HOB 15-30 degree
- keep drainage sys level with tragus (may be ordered to lower if need to drain more)
- assess output hourly
- sudden inc/dec CSF or poor waveform? check cords for plugs or loose connections then call surgeon ASAP
24
Q
Traumatic brain injury
A
head injury that involves scalp, skull, meninges, or brain from mechanical force
25
Why are kids prone to falls?
Most prone--under 5
- lack head control
- lack myelinization and motor fxn (infants)
- mobile spines (under 3)
- head is proportionally larger (toddlers)
- likely to get hit by bike (school agers)
- risk takers (adolescents)
26
Open head injuries
- scalp laceration--superficial, will bleed a lot
- linear skull fracture--single crack in skull (often assoc with bruise)
- depressed skull fracture--broken into several fragments and pushed inward
- basilar skull fracture--break in base of skull
27
Basilar skull fracture sx and NC
- very serious bc proximity to brain stem
- raccoon eyes (SQ bleed around eyes) and battle signs (SQ bruising over mastoid process) common (80%)
- avoid invasive procedures that can introduce a pathogen leading to infx (nothing up nose)
- leakage of CSF possible from ear or nose--contains glucose so can put on gauze and look for yellow ring or try to test on glucose strip
- can easily lead to infx
28
Closed head injuries
- concussion
- contusion—local bruise caused by bleeding
- cerebral laceration
- brain stem injury
- hemorrhage in epidural, subdural, subarachnoid, intracerebral
29
Concussion
Alteration in mental statue w/ or w/o loss of consciousness immediately after blow to the head
- r/o
- Hallmark signs—amnesia and confusion
- other signs—vision chx, nausea, drowsy, HA, dizzy, sensitivity to noise, ringing in ears, hyperexcitability
30
When to seek tx for concussion
- for infants
- pt lost consciousness
- won’t stop crying
- complains of head and neck pain
- vom repeatedly
- hard to wake
- not walking normally (sign of inc ICP)
- v hard to console
- head and neck pain
- bleed from nose or mouth
- watery discharge from nose or ears (suspect CSF)
31
TBI CM
MINOR
- may or may not lose consciousness
- transient confusion
- somnolence
- listless and drowsy
- irritable
- pallor
- vom
SEVERE
- inc ICP
- rental hemorrhage
- extrocular palsies
- hemiparesis
- inc temp
- unsteady gait
32
TBI management
- establish ABCs
- stabilize neck and spine
- freq neuro assessment and vs monitor
- hypertonic solutions (mannitol, hypertonic)—draws fluid into vasculature and away from brain
- steroids to decrease inflammation and edema
- be careful for pain meds—don’t want to sedate
33
TBI complications
- hemorrhage (epidural or subdural)
- posttraumatic meningitis—basilar skull fracture
- brain stem herniation
- hypothalamic dysfunction (altered pituitary secretion)
- SIADH
- diabetes inspidus
- cerebral edema
34
TBI signs of progress
- mental status change
- mounting agitation
- dev of focal lateral neuro signs
- marked chx in VS, Cushing reflex
- brain stem involvement—breathing, pulse, widening pulse pressure
35
Meningitis
Syndrome caused by inflam of meninges of the brain and spinal cord
- caused by H influenza, strep, TB
- often preceded by infx like ear or upper resp
- seen often in late infancy or todderhood
36
Meningitis CM
Newborn—poor suckling and feeding, apnea, weak cry, diarrhea, tense fontanelles, jaundice
Infancy—fever, poor feeding, nausea and vom, inc irritability, high pitch cry, sz
Children—fever, HA, Nuchal rigidity (Brudzinski’s sign—hurts when put chin to chest), Kernig’s sign, opisthotonos (arched back), sz, altered sensorium, projectile vom, chx in LOC
37
Meningitis long-term complications
- blindness—extends to cranial nerves
- deafness
- intellectual disabilities
- hydrocephalus
- loss of extremities
- sz
- cerebral palsy
38
Types of meningitis
- bacterial—worse, permanent damage
- viral—vanishing, usually not lasting complications
39
Meningitis dx
- Lumbar puncture shows inc WBC, pressure and dec protein, low CSF glucose and positive culture (live organisms need the glucose for energy)
- fluids
- meds—abx (if bacterial &/or until CSF cultures return in 48h), anticonvulsants, antipyretics
40
Meningitis NC
- isolate as soon as suspected (droplet)
- labs drawn before abx start, urine, LP
- prevention of complications
- abx ASAP
- sz precautions
- prevent inc ICP
- monitor VS hourly
- monitor for septic shock, circ collapse, dilutional hyponatremia, long-term squelae
- adequate hydration and nutrition
- parental support and reassurance
41
Encephalitis
Inflam process of CNS caused by variety or orgs
- most caused by Herpes simplex virus
42
Encephalitis s/s
- initially nonspecific, fever, AMS, possible sz
- CM can resemble meningitis, lasting neuro sx, death
43
Encephalitis diagnosis and care
- r/o meningitis
- repeated CT scans and watch edema areas, get more CT, may see hemorrhagic area later; monitor progress
- blood samples determine organism
- low stimuli enviro
- observe and support, encourage food
- similar to that of unconscious child
44
Reye syndrome
Acute progressive encephalopathy involving liver dysfunction and appearing several days after apparent recovery from viral illness like varicella or influenza A
- associated with flu/cold/varicella treated with aspirin
- leads in school age
45
Reye syndrome CM
- cerebral edema
- large fatty liver (malfunctioning)
- Prodromal—malaise, cough, rhinorrhea, sore throat, fever
- profuse vom and neuro impairment
46
Reye syndrome patho
Mitochondrial insult indicused by viruses, drugs, exogenous toxins, and genetic factors cause fatty changes in liver, ammonia builds up from liver dysfunction and cerebral edema occurs
- elevated serum ammonium levels correlate with CM and prognosis
47
Reye therapeutic management
- PREVENT—kids no aspirin therapy unless ordered and NOT if they have viral infx
- maintain effective cerebral perfusion and monitor ICP
- meds—muscle paralysis, anticonvulsant, diuretics
- may need mechanical vent or F&E replacement
- monitor lab studies to determine impaired coagulation (PTT)
- death or long-term defects occur in 1/3 pt
48
Reye sx NC
- prevent complications
- monitor glucose q2-4h
- admin meds and fluids as ordered
- sz precautions
- monitor bleeding and liver fxn PT&PTT
- assess for inc ICP q2h
- elevate HOB 30% w/ head in neutral position
- provide dev appropriate stimuli, toys, activities
- balance fluid intake to prevent dehydration and edema
49
Epilepsy
2+ sz episodes not caused by reversible medical conditions like hypoglycemia
- classified by type and etiology
- partial or generalized
50
Epilepsy patho
- abnormal electrical impulses in brain
- hyperexcitable cells are the epileptogenic focus and location determine sz activity characteristics
- misfiring/hyperexcitable
51
Febrile seizures
febrile child (over 101) age 6M-5Y w/o known epilepsy, CNS infx, or metabolic abnormalities has a sz
- usually generalized tonic clonic and last under 15min
- degree ht of seizure contributes more than the velocity with which the temp rose
- 1/3 kids with febrile sz will have 2+ sz but very few get epilepsy
- usually tonic-clonic
52
Febrile sz tx
- lasts longer than 5 min, call EMS and watch
- usually not tx with meds
- monitor airway, O2 sat
- prolonged sz may get rescue sedative like a pam
- not put on long-term sz med
53
Epilepsy dx
- eval if have more than 1 sz NOT related to fever
- video electroencephalogram (VEEG)—watch brain waves for couple days and wait to have sz; get recordings to determine cause, brain location
54
Epilepsy management and SE
- antiepilectic drugs like levetiracetam, carbamazepine, topiramate, lamotrigine, valproic acid
- often begin with low dose and inc, often have multiple drugs at lower doses; can start to slowly wean if sz free for 6M (one med at a time)
- SE: aplastic anemia, sedation, somnolence, wt loss, hyperactivity, ataxia
- ketogenic diet—high fat, low carb, adequate protein; body shifts from glucose to fat as main energy; may give supplement vitamins; short-term
- vagus nerve stimulation—implanted device that stops sz after it starts when magnet is placed on it by caregiver; electrodes under skin give electrical impulses to vagus nerves; used when AEDs fail to control; kids over 12
- surgery to remove cerebral tissue/misfiring cells—LAST RESORT
55
Active sz NC
- observe sz directly (eye mvt, altered LOC, unilateral/bilateral mvt)
- monitor airway, risk for aspiration
- protect from injury, lower bed, protect head, don’t restrain or put anything in MOUTH
- vitals and blow by blow oxygen (if O2 under 90%)
- if longer than 5min or clustering occurs; status epilepticus, give rescue meds like pams
- call HCP and stay with them
56
Long-term epilepsy NC
- educate caregiver regarding rescue med
- keep rescue meds w/ child at all times (school and home)
- avoid triggers—stress, sleep deprivation, flickering/strobe light
- safety—don’t swim or bathe alone, wear helmet, avoid open flames and tall heights
- fam support and edu, promote Ind and being a child
- SE management
