Peds neuro

Injuries in children Unintentional injuries are the leading cause of death in children 0‐19 years

ll MVC #1 cause overall‐MVC Occupants Pedestrians and pedestrian cyclistsp y

Wolters Kluwer‐Lippincott Williams and Wilkens

Leading causes of death by ageLeading causes of death by age group <1 yr‐ suffocation 1‐4 years‐ drowning 5‐19 years‐ vehicle passenger


Not all injuries lead to death #1 cause of non‐fatal injuries in children 0‐15 years

falls


Differences in Anatomy and Physiology of the Neurologic System of ChildrenSystem of Children First 3 to 4 weeks’ gestation

Infection trauma teratogens and malnutrition can cause physical Infection, trauma, teratogens, and malnutrition can cause physical defects and may affect normal CNS development.

BirthC i l b ll d l d b t t f d i d i k f Cranial bones well developed, but not fused: increased risk for fracture

Brain is highly vascular: increased risk for hemorrhage Child

Spinal cord is mobile: high risk for cervical spine injury


Anatomic differencesAnatomic differences Head is large in proportion to body

Increased risk of head injury d/t falls Increased risk of head injury d/t falls Fastest growing body part during infancy until age 5


Neurologic development Development is complete but immature at birth

Myelination is incompleted h l d l d h d d k Proceeds in a cephalo‐caudal direction‐ head and neck

control before trunk and extremities

Open sutures allow for brain growthp g


Neurologic AssessmentHistory/ Physical Exam

Past Medical History Prenatal exposures – teratogenic exposure, substance abuse,

maternal anemia, maternal illness, maternal malnutrition, lack of , , ,folic acid

Birth history – trauma, hypoxia, low Apgars, prolonged labor Significant past medical history (baby) – birth anomalies, Significant past medical history (baby) birth anomalies,

prematurity, ingestion of toxins, surgeries, infections Developmental milestones – delays? , progression of speech,

language and playg g p y Family history – seizure disorders?, mental retardation?,

hereditary disorders, neural tube defects

Neuro HPI Nausea/vomiting Vision changesHA/ h t h bi HA/photophobia

Neck stiffness Poor feeding Poor feeding Inconsolability Lethargygy Fever Ataxia Trauma history


Neuro exam Inspection ,observation, and palpation

Level of consciousnessb l l h l b l Extreme irritability or lethargy/consolability

Pediatric GCS

Head circumferenceHead circumference Important in detecting potential neurologic conditions

Acute changes/changes over timel ( f ll ll l h Fontanels (anterior fontanelle generally open until 18 months

of age) Should be soft and flat


Neuro exam Pupil reaction EOM’s Muscle tone

Symmetry, strengthP i (l i ) Posturing (late sign)

Signs of increased ICPE l l t i h t 6 6 i t t Early versus late signs‐ chart 16.1, page 506 in text



Signs of increased ICPSigns of increased ICPEarly Infancy Increased ICP Assessment Findings *** Change in LOC‐ Irritability, lethargy Bulging fontanels, progressive head enlargementg g , p g g Persistent vomiting, FTT Delay or loss of developmental milestones Sunset eyes Sunset eyes ***Late Signs‐ High, shrill cry Seizures Seizures Change in Vital Signs

Bradycardia, hypertension, respiratory depression‐“Cushing’s triad”


Increased ICPIncreased ICPOlder Child Increased ICP Assessment Findings

***Headache nausea/ vomiting Headache, nausea/ vomiting Irritability or change in personality Gait disturbances, vertigo Blurred Vision sunset eyes Blurred Vision, sunset eyes Worsening school performance

S Late Signs ** Significant decrease in LOC Change in Vital Signs‐ Cushings Triad

i d/ dil d il Fixed/ dilated pupils


Acute nursing management of aAcute nursing management of a child with increased ICP Frequent neuro assessment Frequent vital signs Elevate HOB 15‐30 degrees

Facilitates venous return and decreases ICPd l l bl Have emergency equipment readily available

Increased ICP can result in respiratory/cardiac failure


Types of Neurologic Disorders inTypes of Neurologic Disorders in Children Structural disorders

Hydrocephalus MyelomeningoceleMyelomeningocele

Seizure disorders Infectious disorders

Meningitis Trauma to the neurologic system

Concussions Chronic disorders

Cerebral palsyBl d fl di i di d Blood flow disruption disorders


Hydrocephalus( ) ( ) Derived from the Greek, hydor (water) & kephale (head).

Accumulation of fluid (CSF, blood) in the ventricles of ( , )the brain (impedance of flow, production or absorption).

As CSF increases, the ventricles dilate ‐‐‐> pressure , pincreases within the intracranial vault

INCREASED ICP

CSF‐ secreted by choroid plexus.

Adults/ Children ‐‐> 500cc/day, Infants ‐‐> 25ml/day/ 5 / y, 5 / y


Hydrocephalus Etiology

Congenital‐d l fl d Genetic predisposition or environmental influences during

fetal development

Acquiredq Trauma Intraventricular hemorrhage, infection, tumors, etc

Cl ifi i Classification Communicating‐ impaired absorption –too much CSF Non communicating anatomical obstruction Non‐communicating‐ anatomical obstruction


Hydrocephalus

Hydrocephalus‐treatment Aqueductal stenosis

Most common type of obstructive hydrocephalusobstructive hydrocephalus

Narrowing of the aqueduct of sylvius( b t rd d (passage between 3rd and 4th ventricles

Endoscopic third ventriculostomy (ETV) Hole made in bottom of 3rd

ventricle Avoids need for a shunt


Ventriculoperitoneal shunt

Placement of a VP shunt. Reprinted from 'Principles of Neurosurgery,' 2nd edition, Edited by Setti S. Rengachary, Richard G. Ellenbogen, Copyright (2005)

Shunts Ventriculoperitoneal Ventriculoatrial Ventriculolumbar

Parts of a shunt CatheterP i h b Pumping chamber

One way valve Distal catheter Distal catheter


Hydrocephalus What should the nurse monitor for post‐op after

a VPS placement? Vital signs Vital signs S/S increasing ICP I and O Changes in neuro status Changes in neuro status, exam, LOC and GCS Observe shunt surgical sites‐head and abdomen Pain status Keep HOB 30 degreesp 3 g


The Neural Tube

l b D f Neural Tube Defect: Example: Myelomeningocele

“Spina Bifida” Spina Bifida

Myelomeningocele Neural tube fails to close at the end of the 4th week of gestationS i l d f d l l f d f Spinal cord often ends at level of defect Absent motor and sensory function beyond that point

L t li ti Long term complications Paralysis Orthopedic deformities Orthopedic deformities Bowel and bladder incontinence


Seizures Abnormal electrical discharge of nerve cells in

brain ‐‐‐> loss of consciousness, involuntary movement, behavior &/or sensory alterations.ove e t, be av o &/o se so y a te at o s.

Epilepsy‐ chronic seizure disorder due to an d l i b i b liunderlying brain abnormality


Seizures Occur in approximately 10% of children Fever, infection, trauma, hypoxia, toxins, cardiac

arrhythmia’sarrhythmias Familial tendency Unknown cause


Seizures Two major categories

Partial‐ large proportion of childhood seizuresl Simple

Complex

GeneralizedGeneralized


Types of Seizures 1. Simple partial seizures‐ Focal ‐ Localized body part ‐ No LOC; No post‐seizure confusion; ; p ; no aura ‐ ~30 secs.

2. Complex partial Seizures‐ Psychomotor ‐ Impaired consciousness‐‐‐>automatisms (may

l d )progress to a generalized seizure) ‐ aura, anxiety/ fear afterwards ‐ ~30secs. ‐ 5 mins.30secs. 5 mins.


Partial seizures Simple partial seizures

Sx’s depend on which area of brain affected Tonic/clonic movements of face neck extremities‐localizedTonic/clonic movements of face, neck, extremities localized Child remains conscious‐ no postictal state Last a short time‐ ~30 sec.C l i l Complex partial May have preceding aura Impaired consciousnessp

Repetitive movements (automatisms) picking/pulling Infants‐ lip smackingg

Hard to control


Generalized seizures Tonic clonic‐ “grand mal”

Associated with an aura Post‐ictal phasep Loss of sphincter and bladder control is common Entire body contractions http://youtu.be/WsBKg2PtQWcp y g Q

Absence Sudden cessation of motor activity or speech “staring spells”staring spells Very brief‐ 3‐5 seconds http://youtu.be/bC9672CmkZM http://youtu be/9HiKwTm755o http://youtu.be/9HiKwTm755o


Febrile seizures Most common type of seizure in childhood Usually in children less than 5 Familial predisposition Associated with a fever‐usually viral illness

Rapid rise in temperature Usually a simple seizure

N CNS h ( f i i i if !) No CNS changes (worry for meningitis if so!) No intervention needed

Look for source of fever Look for source of fever


Seizures: Nursing Implications Safety Maintain safe environment during event. Maintain patent airway and adequate oxygenation. Do NOT p y q yg

place anything in child's mouth. Monitor the post‐ictal phase. Administer medications appropriately. Monitor therapeutic

bl d l lblood levels.

Document Date, time and nature of seizure. Note the length of seizure, loss of consciousness, apnea, meds

needed to stop seizure. Precipitating events.


Treatment Anticonvulsants Surgery‐ for intractable seizures Ketogenic diet Vagal nerve stimulator


Grid Placement Surgery:Identify Locality of Seizure ActivityActivity

Seizures Terms to be familiar with...

Aura‐ sensation that gives warning of an impending sz.

Tonic‐ unconsciousness continuous muscle contraction‐ stiffness Tonic unconsciousness, continuous muscle contraction‐ stiffness

Clonic‐ alternating muscular contraction/ relaxation

Status epilepticus‐ prolonged repetitive sz without regain of p p p g p gconsciousness between attacks or one continuous sz

Post‐ictal Phase‐ Decreased LOC after a seizure; may last hours

Febrile Seizures lf li iti t t t d d Febrile Seizures‐ self‐ limiting; no emergency treatment needed; anti‐pyretics; anticonvulsant may be used for the length of the underlying illness

Intractable Seizures‐ occur despite optimal management

Ketogenic Diet‐ hi fat, low‐carb diet → ketosis → reduces epilepsy


Bacterial Meningitis Infection of the meninges, the lining the surrounds the brain and spinal cord

C l d b i d k d f k d Can lead to brain damage, stroke, deafness, stroke and death

Decreased dramatically due to HIB vaccine in USDecreased dramatically due to HIB vaccine in US

Deterioration can be rapidp Need prompt IV antibiotics Lumbar puncture/blood cultures/CBC


Signs In older children

Neck stiffness, h d h fheadache, fever

Babies/young children Opisthotonic position Opisthotonic position Bulging fontanelle Inconsolable Rash


Cerebral PalsyAb l d l d h f Abnormal development or damage to the motor areas of the brain, resulting in a lesion Causes a disruption in the brain’s ability to control

movementmovement Non‐progressive May be associated with sensory, intellectual, emotional or

seizure disorders. Etiology

Anoxic injury Premature birth or intrapartal asphyxia Congenital or perinatal infections Congenital brain anomalies Many others‐ p 818 in textbook

M h i di i ( di bili ) i Most common chronic condition (permanent disability) in childhood.


Cerebral Palsyd Assessment Findings

*** Delayed gross motor development

Usually identified at well baby check‐up‐‐ Not usually identified at birth

Abnormal posturing‐‐most evident with spastic CP

Persistence of primitive infantile reflexes and/or reflex Persistence of primitive infantile reflexes and/or reflex hypersensitivity

M t h t l t d ti May or may not have mental retardation


Cerebral Palsy Classification

Spastic‐ (75%) increased tone (hypertonicity), rigid, poor control of posture, balance and coordination, contracturesp , ,

Athetoid/Dyskinetic‐ (10‐15%) abnormal involuntary movements‐ disappear during sleep, increase with stress

Ataxic‐ (5‐10%) wide‐based gait rapid repetitive movements Ataxic‐ (5‐10%) wide‐based gait, rapid repetitive movements performed poorly

Mixed Types

Cerebral Palsyh l h bl Accompanying health problems

Contractures Pain Feeding problems/ swallowing/ reflux/ nutrition Respiratory problems Dental disease

H i i i Hearing impairment Delayed Speech Mental Retardation S i Seizures Visual impairment (i.e. Strabismus) Functional abilities to perform ADL's Immobility Immobility


Cerebral Palsy Management

** Early recognition is important so that optimum development can be promoted‐mobility it criticalp p y

Physical/ Occupational Therapy Mobility Devices, AFO's (ankle foot orthotics) Promote self‐care activities to maximize ability Promote self‐care activities to maximize ability Pharmacologic‐ Anti‐spasmodics (Baclofen, Botulinum

toxin, diazepam) Surgery Tendon release Achilles tendon lengthening Surgery‐ Tendon release, Achilles tendon lengthening,

Hamstring release


Cerebral Palsy: Tendon Releases

Achilles Tendon Release: Achilles Tendon Release: After this surgery heals, the child may be able to stand flat‐footed.

Femoral Osteotomy

Cerebral Palsy: Splints, AFO's

Head trauma‐Concussions Most common head injury Lots of attention in recent years

Why? Greater understanding of its role as a form of traumatic brain injury injury

Often from a blow or jolt to the head Sports injuriesp j

Kids are more susceptible to injuries than adults

Motor vehicle injuriesll Falls


Concussion signsConcussion signs

Thinking/Remembering

Physical Emotional/Mood

Sleep

Difficulty thinking Headache Irritability Sleeping more than Difficulty thinking clearly

Headache

Fuzzy or blurry vision

Irritability Sleeping more than usual

Feeling slowed down

Nausea or vomiting(early on)

Sadness Sleep less than usualdown (early on)

Dizziness

usual

Difficulty concentrating

Sensitivity to noise or light

More emotional Trouble falling asleepconcentrating or light

Balance problems

asleep

Difficulty remembering new

Feeling tired, having no energy

Nervousness or anxietyg

informationg gy y


Concussion symptoms May or may not have loss of consciousness CT scan and MRI are normal, as it does not result in

l d h b istructural damage to the brain


Return to play A child with a concussion MUST NOT return to play the same day

Sh ld b i hil d i h i Should be asymptomatic while at rest and with exertion before return to play is considered

Closer monitoring during 1st 24‐48 hours after injuryCloser monitoring during 1 24 48 hours after injury Potential for more severe injury needing evaluation


Red Flags! Need to be evaluated Looks very drowsy or cannot be awakened. Unequal pupilsS i Seizures.

Cannot recognize people or places. Are getting more and more confused restless or agitated Are getting more and more confused, restless, or agitated. Have unusual behavior. Loss of consciousness Loss of consciousness Infants/young children

Will not stop crying and cannot be consoled. Will not nurse or eat.

www.cdc.ogv

Prevention of head injuries inPrevention of head injuries in children Proper use of car seats Helmets for sport activities Safety gates and window guards for young children Safe, absorbent playground surfaces

www.cdc.ogv

Thank you


Documents

Peds neuro