Alterations in Neurological Function in Pediatrics

1. Alterations in Neurological Function in Pediatrics Christine Limann, RN, CPN

2. Pediatric Differences -Head is larger in proportion to body -Insufficient musculoskeletal support in neck -Fontenelles not closed in young child -How does the pediatric head differ from the adults? How does this put them at greater risk? -Scalp is very vascular. Because head is disproportionately larger, children also have increased risk of bleeding from head injury. -How does the pediatric head differ from the adults? How does this put them at greater risk? -Scalp is very vascular. Because head is disproportionately larger, children also have increased risk of bleeding from head injury.

3. -Major cause of childhood deaths -Who is more at risk? It is not only their anatomical differences, but also the teenage perception that they are invincible. This is referred to as the personal fable (Saewyc, 2007). Injury is the greatest health hazard for adolescents (Ball, Bindler, & Cowen, 2010). Injuries are twice as common in boys than girls. What activities do kids do that can increase their risks? According to Saewyc, (2007), motorized vehicle crashes are the number one source of unintentional injury and death. Falls – leading cause of head injuries under 5 yearsIt is not only their anatomical differences, but also the teenage perception that they are invincible. This is referred to as the personal fable (Saewyc, 2007). Injury is the greatest health hazard for adolescents (Ball, Bindler, & Cowen, 2010). Injuries are twice as common in boys than girls. What activities do kids do that can increase their risks? According to Saewyc, (2007), motorized vehicle crashes are the number one source of unintentional injury and death. Falls – leading cause of head injuries under 5 years

4. Concussion Mild brain injury, but can lead to more problems if a second injury occurs before brain has healed. Transient and reversible. What is “Second impact syndrome”? Complete Link: http://www.youtube.com/watch?v=_CSw7hqpeCYMild brain injury, but can lead to more problems if a second injury occurs before brain has healed. Transient and reversible. What is “Second impact syndrome”? Complete Link: http://www.youtube.com/watch?v=_CSw7hqpeCY

5. Cerebral Contusion Bruising of the brain secondary to blunt trauma. Can be either coup or countercoup injuries. May involve tearing of brain tissue and may lead to areas of necrosis or infarction. What are the differences between concussion and contusion? If there is a skull fx, there’s an increased risk of bleedingWhat are the differences between concussion and contusion? If there is a skull fx, there’s an increased risk of bleeding

6. Head Trauma Between dura and cerebellum Result of head trauma such as falls, MVA, or shaken child syndrome Symptoms may appear after 24-72 hours Change in LOC, Headache, N/V, retinal hemorrhage, pupil on side of injury may be dilated Prognosis poor Between dura and skull Almost never occurs in children less than 4 y/o. Blunt trauma such as MVA, assault, baseball injury Delayed onset followed by rapid change in mental status Headache, Fixed dialated pupils, s/s increased ICP Prognosis good Subdural Hematoma Epidural Hematoma Epidural- Between skull and outer layer of dura matter Subdural- Between the layers of the dura matter Why is a lumbar puncture not a good idea on a trauma or head injury?Epidural- Between skull and outer layer of dura matter Subdural- Between the layers of the dura matter Why is a lumbar puncture not a good idea on a trauma or head injury?

7. Shaken Baby Physical abuse Countercoup injury Subdural Hematoma Retinal Hemorrhage Seizure Check baby for fractures in the rest of their body Shaken Baby=Subdural S=S DCFS involvement The infants head has an increased range of motion compared to an adults with insufficient musculoskeletal support.Shaken Baby=Subdural S=S DCFS involvement The infants head has an increased range of motion compared to an adults with insufficient musculoskeletal support.

8. Injury by Severity Concussion or mild brain injury 13-15 GCS Moderate brain injury 9-12 GCS Loss of consciousness Severe Brain Injury 8 or less GCS Coma Increased ICP High pitched “cat like” cry, sign of brain injury in infant. Can you have a GCS of “0”?High pitched “cat like” cry, sign of brain injury in infant. Can you have a GCS of “0”?

9. Nursing Actions What is the priority? Reportable changes Decrease in coma scale Restlessness and irritability Pain Changes in pupils Changes in responses, reflexes, movements Drainage from nose/ears Increased thirst or urination Change in vital signs

10. Cushing’s Triad Late signs of ICP. Medical emergency. Late signs of ICP. Medical emergency.

11. Intracranial Infections -Meningitis More Dangerous Group B Streptococcus and gram-negative enteric bacilli most likely cause in newborns Neisseria Meningitidis 2 mo-12 yr Can also cause meningococcemia H influenzae B and Strep Pneumoniae are now less common because of vaccination -Fever, vomiting, irritable, hemorrhagic rash, headache, nuchal rigidity, seizures Treatment: Antibiotics Does not appear as ill as the child with bacterial meningitis Caused by enteroviruses, mumps, vericella Irritable, fever, lethargy, headache, may have stick neck or back pain Usually resolves in 3-10 days Treat with antibiotics until bacterial meningitis is ruled out Bacterial Meningitis Viral Meningitis What is meningitis? Acute inflammation of CNS. Why are infections often missed? Are they contagious? Nursing priority-start antibiotics Meningococcemia- most severe Neisseria Meningitidis. – Immune response to endotoxins of the organisms. New research has shown that dexamethasone IV has also been effective in adult cases of bacterial meningitis (Neurology, 2009). What is meningitis? Acute inflammation of CNS. Why are infections often missed? Are they contagious? Nursing priority-start antibiotics Meningococcemia- most severe Neisseria Meningitidis. – Immune response to endotoxins of the organisms. New research has shown that dexamethasone IV has also been effective in adult cases of bacterial meningitis (Neurology, 2009).

12. Intracranial Infections-Reye’s Syndrome Infection in the brain – acute encephalopathy May cause permanent tissue damage to brain and liver Associated with use of aspirin with viral illness such as chicken pox or influenza b Symptoms: nausea/vomiting, mental changes, seizures, progressive unresponsiveness The condition has become rare since 1980’s, but the mortality rate of children who develop the disorder is still high (Ball, Bindler, & Cowen, 2010). This is a PICU patient who may require mechanical ventilation if comatose. -Remember aspirin is transferable in breast milk The condition has become rare since 1980’s, but the mortality rate of children who develop the disorder is still high (Ball, Bindler, & Cowen, 2010). This is a PICU patient who may require mechanical ventilation if comatose. -Remember aspirin is transferable in breast milk

13. Hydrocephalus – Cerebrospinal fluid build up Communicating hydrocephalus – no blockage. Either a problem with over production of CSF or problem with absorption Non-communicating- obstruction Communicating-The CSF flows freely, but absorption in the subarachnoid space is impaired. Non-communicating – Majority of cases. Obstruction in the ventricular system. Communicating-The CSF flows freely, but absorption in the subarachnoid space is impaired. Non-communicating – Majority of cases. Obstruction in the ventricular system.

14. Causes of Hydrocephalus Myelomeningocele Dandy-Walker Syndrome Chiari Malformation Aqueduct of sylvius stenosis Intraventricular hemorrhage in premature infants Post infectious meningitis Brain tumors Congenital malformation Non-Congenital Myelomeningocele-type of spina-bifida, often have hydrocephalus Dandy-walker – posterior fossa blocked by cyst Chiari Malformation- foramen magnum is blocked causing csf build up Myelomeningocele-type of spina-bifida, often have hydrocephalus Dandy-walker – posterior fossa blocked by cyst Chiari Malformation- foramen magnum is blocked causing csf build up

15. Hydrocephalus- clinical manifestations Newborns and infants Bulging fontanels Increased head circumference Sun set eyes Irritability High-pitched, catlike cry Visible scalp veins Children Headache Visual disturbance Nausea/vomiting Pupils sluggish Decrease in consciousness Seizures Cushing’s Triad Widening pulse pressure Bradycardia Irregular respirations -What symptoms do you think parents will notice? -Children can verbalize their head hurts. “My shunt hurts” Infants tolerate ICP better because skull expands at Fontenelles. Body is actually “adapting” to the problem. -What symptoms do you think parents will notice? -Children can verbalize their head hurts. “My shunt hurts” Infants tolerate ICP better because skull expands at Fontenelles. Body is actually “adapting” to the problem.

16. Hydrocephalus Treatment Ventriculoperitoneal shunt (VP Shunt) What do you think is the most common complication? What do you need to teach parents? How should you position after surgery?What do you think is the most common complication? What do you need to teach parents? How should you position after surgery?

17. Seizures Most common neurologic dysfunction in kids Caused by malfunctions of brain’s electrical system Infections or high fever Chemical imbalance of the body that causes loss of metabolism Congenital conditions or trauma Genetic factors and family history Brain tumors and neurological problems Habits of the mother like smoking, alcohol consumption, drugs and certain medications Has anyone ever been around someone having a seizure? Has anyone ever been around someone having a seizure?

18. Types of Seizures Absence – (3-12 years old)5-10 sec. Lip smacking, staring, twitching, brief loss of consciousness Partial (focal) – Less than 30 sec., one extremity Generalized (tonic-clonic or grand mal) Febrile Dependent Epilepsy – Chronic disorder Absence seizures may look like daydreaming and can cause problems for school age children (Ball, Bindler, & Cowen, 2010).- Absence seizures may look like daydreaming and can cause problems for school age children (Ball, Bindler, & Cowen, 2010).-

19. Febrile Seizures Usually higher than 38.9 C or 101F Usually short in duration. Instruct parents to call 911 if longer than 5 minutes Use antipyretics and cooling measures If this is a first time seizure, the doctor should be notified even if it lasts on a few seconds (Mayo Clinic, 2010). Rare after 5 years old and more common in males (Hockenberry & Wilson, 2010). Usually not treated with anticonvulsants because seizures usually end before they get to emergency care (Ball, Bindler, & Cowen,2010) If this is a first time seizure, the doctor should be notified even if it lasts on a few seconds (Mayo Clinic, 2010). Rare after 5 years old and more common in males (Hockenberry & Wilson, 2010). Usually not treated with anticonvulsants because seizures usually end before they get to emergency care (Ball, Bindler, & Cowen,2010)

20. Nursing actions with patients with seizures Before Where there triggers such as change in temperature, light? During Maintain airway Role to side if possible Time changes started Part of the body involved and movement Incontinence After Do they remember what happened? Don’t leave the patient. Call for help. Don’t put anything in their mouth, but maintain their airway. Do activity about questions parents might have. Safety at home –Bathtub, swimmingDon’t leave the patient. Call for help. Don’t put anything in their mouth, but maintain their airway. Do activity about questions parents might have. Safety at home –Bathtub, swimming

21. Treatment for Seizures Common pharmacological choices Ativan -Lorazepan Diazepam – Diastat (can be given rectally) Phenobarbital or Phenytoin Remind parents not to stop once the seizures are controlled until directed by a doctor. Other types of treatment Vagal Nerve stimulator Ketogenic Diet Also consider that as children grow, their doses may change. Must monitor blood levels- Phenobarbital. Decrease in dosage for long term use may begin when patient has been seizure free for 2 years and EEG is normal (Hockenberry & Wilson, 2010). Also consider that as children grow, their doses may change. Must monitor blood levels- Phenobarbital. Decrease in dosage for long term use may begin when patient has been seizure free for 2 years and EEG is normal (Hockenberry & Wilson, 2010).

22. Nursing Role: Provide adequate Nutrition Promote safety and physical mobility Maintain Skin Integrity Prevent Constipation Cerebral Palsy High calorie diet or supplements may be necessary. A g-tube may be necessary if patients cannot chew and swallow without aspiration. (Ball, Bindler, & Cowen, 2010) High calorie diet or supplements may be necessary. A g-tube may be necessary if patients cannot chew and swallow without aspiration. (Ball, Bindler, & Cowen, 2010)

23. Spina Bifida Surgery to close the repair usually occurs within 24-48 hours. Some cases can be repaired in utero. May need VP shunt. Ongoing therapy Mobility-Braces, wheelchair Neurogenic bowel and bladder How is it prevented? More difficult to walk as patient gets bigger. Bowel and bladder becomes more problematic as children get older. Remember that most do not have mental delays. (Ball, Bindler, & Cowen, 2010)How is it prevented? More difficult to walk as patient gets bigger. Bowel and bladder becomes more problematic as children get older. Remember that most do not have mental delays. (Ball, Bindler, & Cowen, 2010)

25. References Ball, J., Bindler, R., & Cowen, K. (2010).Child Health Nursing: Partnering with Children & Families 2nd Ed. Upper Saddle River, NJ. Pearson. Hockenberry, M. & Wilson, D. (2010). Wong’s Nursing Care of Infants and Children 8th Edition. St. Louis, MO. Elsevier. Mayoclinic.com (2010). Febrile Seizure. Retrieved from http://www.mayoclinic.com/health/febrile-seizure/DS00346/DSECTION=symptoms Saewyc, E. (2007). Health Promotion of the Adolescent and Family. In Hockenberry, M. & Wilson, D. (Eds.) Wong’s Nursing Care of Infants and Children 8th Edition (pp. 811-848). St. Louis, MO. Elsevier. Do EvalsDo Evals