3. Leading causes of death by age
Leading causes of death by age
group
<1 yr‐ suffocation
1‐4 years‐ drowning
5‐19 years‐ vehicle passenger
Wolters Kluwer‐Lippincott Williams and Wilkens
5. Differences in Anatomy and
Physiology of the Neurologic
System of Children
System 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.
Birth
CCranial bones well developed, but not fused: increased risk for
i l b ll d l d b t t f d i d i k f
fracture
Brain is highly vascular: increased risk for hemorrhage
Child
Spinal cord is mobile: high risk for cervical spine injury
Wolters Kluwer‐Lippincott Williams and Wilkens
8. Neurologic development
Development is complete but immature at birth
Myelination is incomplete
Proceeds in a cephalo‐caudal direction‐ h d d
d h l d ld head and neck
k
control before trunk and extremities
Open sutures allow for brain growth
p g
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9.
10. Neurologic Assessment
History/ 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,
prematurity, ingestion of toxins, surgeries, infections
Developmental milestones – delays? , progression of speech,
g g p y
language and play
Family history – seizure disorders?, mental retardation?,
hereditary disorders, neural tube defects
11. Neuro HPI
Nausea/vomiting
Vision changes
HA/photophobia
HA/ h t h bi
Neck stiffness
Poor feeding
Inconsolability
Lethargy
gy
Fever
Ataxia
Trauma history
Wolters Kluwer‐Lippincott Williams and Wilkens
12. Neuro exam
Inspection ,observation, and palpation
Level of consciousness
Extreme irritability or lethargy/consolability
bl l h l bl
Pediatric GCS
Head circumference
Important in detecting potential neurologic conditions
Acute changes/changes over time
Fontanels (anterior fontanelle generally open until 18 months
l ( f ll ll l h
of age)
Should be soft and flat
Wolters Kluwer‐Lippincott Williams and Wilkens
13. Neuro exam
Pupil reaction
EOM’s
Muscle tone
Symmetry, strength
PPosturing (late sign)
i (l i )
Signs of increased ICP
E l
Early versus late signs‐ chart 16.1, page 506 in text
l t i h t 6 6 i t t
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16. Signs of increased ICP
Signs of increased ICP
Early Infancy
Increased ICP Assessment Findings
*** Change in LOC‐ Irritability, lethargy
Bulging fontanels, progressive head enlargement
g g ,p g g
Persistent vomiting, FTT
Delay or loss of developmental milestones
Sunset eyes
***Late Signs‐
High, shrill cry
Seizures
Change in Vital Signs
Bradycardia, hypertension, respiratory depression‐
“Cushing’s triad”
Wolters Kluwer‐Lippincott Williams and Wilkens
17. Increased ICP
Increased ICP
Older 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
Late Signs
S
** Significant decrease in LOC
Change in Vital Signs‐ Cushings Triad
Fixed/ dilated pupils
i d/ dil d il
Wolters Kluwer‐Lippincott Williams and Wilkens
18. Acute nursing management of a
Acute nursing management of a
child with increased ICP
Frequent neuro assessment
Frequent vital signs
Elevate HOB 15‐30 degrees
Facilitates venous return and decreases ICP
Have emergency equipment readily available
dl l bl
Increased ICP can result in respiratory/cardiac failure
Wolters Kluwer‐Lippincott Williams and Wilkens
19. Types of Neurologic Disorders in
Types of Neurologic Disorders in
Children
Structural disorders
Hydrocephalus
Myelomeningocele
Seizure disorders
Infectious disorders
Meningitis
Trauma to the neurologic system
Concussions
Chronic disorders
Cerebral palsy
Bl d fl di
Blood flow disruption disorders
i di d
Wolters Kluwer‐Lippincott Williams and Wilkens
20. 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
, p
increases within the intracranial vault
INCREASED ICP
CSF‐ secreted by choroid plexus.
Adults/ Children ‐‐> 500cc/day, Infants ‐‐> 25ml/day
/ 5 / y, 5 / y
Wolters Kluwer‐Lippincott Williams and Wilkens
21. Hydrocephalus
Etiology
Congenital‐
Genetic predisposition or environmental influences during
d l fl d
fetal development
Acquired
q
Trauma
Intraventricular hemorrhage, infection, tumors, etc
Cl ifi i
Classification
Communicating‐ impaired absorption –too much CSF
Non communicating anatomical obstruction
Non‐communicating‐
Wolters Kluwer‐Lippincott Williams and Wilkens
23. Hydrocephalus‐treatment
Aqueductal stenosis
Most common type of
obstructive hydrocephalus
Narrowing of the
aqueduct of sylvius
(passage between 3rd and
( b t d
4th ventricles
Endoscopic third
ventriculostomy (ETV)
Hole made in bottom of 3rd
ventricle
Avoids need for a shunt
Wolters Kluwer‐Lippincott Williams and Wilkens
24. Ventriculoperitoneal shunt
Placement of a VP shunt. Reprinted from 'Principles of Neurosurgery,' 2nd edition,
Edited by Setti S. Rengachary, Richard G. Ellenbogen, Copyright (2005)
25. Shunts
Ventriculoperitoneal
Ventriculoatrial
Ventriculolumbar
Parts of a shunt
Catheter
PPumping chamber
i h b
One way valve
Distal catheter
Wolters Kluwer‐Lippincott Williams and Wilkens
26. Hydrocephalus
What should the nurse monitor for post‐op after
a VPS placement?
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 degrees
p 3 g
Wolters Kluwer‐Lippincott Williams and Wilkens
27. The Neural Tube
Neural Tube Defect:
l b D f
Example: Myelomeningocele
“Spina Bifida”
Spina Bifida
28. Myelomeningocele
Neural tube fails to close at the end of the 4th week of
gestation
S 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
Long term complications
t li ti
Paralysis
Orthopedic deformities
Bowel and bladder incontinence
Wolters Kluwer‐Lippincott Williams and Wilkens
29.
30. Seizures
Abnormal electrical discharge of nerve cells in
brain ‐‐‐> loss of consciousness, involuntary
ove e t, be av o &/o se so y a te at o s.
movement, behavior &/or sensory alterations.
Epilepsy‐ chronic seizure disorder due to an
underlying brain abnormality
d l i b i b li
Wolters Kluwer‐Lippincott Williams and Wilkens
31. Seizures
Occur in approximately 10% of children
Fever, infection, trauma, hypoxia, toxins, cardiac
arrhythmia s
arrhythmia’s
Familial tendency
Unknown cause
Wolters Kluwer‐Lippincott Williams and Wilkens
32. Seizures
Two major categories
Partial‐ large proportion of childhood seizures
Simple
l
Complex
Generalized
Wolters Kluwer‐Lippincott Williams and Wilkens
33. 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
progress to a generalized seizure)
l d
‐ aura, anxiety/ fear afterwards
‐ ~30secs. ‐ 5 mins.
30secs.
Wolters Kluwer‐Lippincott Williams and Wilkens
34. Partial seizures
Simple partial seizures
Sx’s depend on which area of brain affected
Tonic/clonic movements of face neck extremities‐localized
movements of face, neck, extremities localized
Child remains conscious‐ no postictal state
Last a short time‐ ~30 sec.
CComplex partial
l i l
May have preceding aura
Impaired consciousness
p
Repetitive movements (automatisms)
picking/pulling
Infants‐ lip smacking
g
Hard to control
Wolters Kluwer‐Lippincott Williams and Wilkens
35. Generalized seizures
Tonic clonic‐ “grand mal”
Associated with an aura
Post‐ictal phase
p
Loss of sphincter and bladder control is common
Entire body contractions
http://youtu.be/WsBKg2PtQWc
p 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
Wolters Kluwer‐Lippincott Williams and Wilkens
36. 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
No CNS changes (worry for meningitis if so!)
( f i i i if !)
No intervention needed
Look for source of fever
Wolters Kluwer‐Lippincott Williams and Wilkens
37. 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
blood levels.
bl d l l
Document
Date, time and nature of seizure.
Note the length of seizure, loss of consciousness, apnea, meds
needed to stop seizure.
Precipitating events.
Wolters Kluwer‐Lippincott Williams and Wilkens
38. Treatment
Anticonvulsants
Surgery‐ for intractable seizures
Ketogenic diet
Vagal nerve stimulator
Wolters Kluwer‐Lippincott Williams and Wilkens
40. Seizures
Terms to be familiar with...
Aura‐ sensation that gives warning of an impending sz.
Tonic unconsciousness, continuous muscle contraction‐
Tonic‐ unconsciousness continuous muscle contraction‐ stiffness
Clonic‐ alternating muscular contraction/ relaxation
Status epilepticus‐ prolonged repetitive sz without regain of
p p p g p g
consciousness between attacks or one continuous sz
Post‐ictal Phase‐ Decreased LOC after a seizure; may last hours
Febrile Seizures‐ lf limiting; no emergency treatment needed;
Febrile Seizures self‐ li iti t t t d d
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
Wolters Kluwer‐Lippincott Williams and Wilkens
42. Signs
In older children
Neck stiffness,
headache, fever
h d h f
Babies/young children
Opisthotonic position
Bulging fontanelle
Inconsolable
Rash
Wolters Kluwer‐Lippincott Williams and Wilkens
43. Cerebral Palsy
Abnormal development or damage to the motor areas of
Ab l d l d h f
the brain, resulting in a lesion
Causes a disruption in the brain’s ability to control
movement
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.
Wolters Kluwer‐Lippincott Williams and Wilkens
44. Cerebral Palsy
Assessment Findings
d
*** 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
hypersensitivity
M
May or may not h
t have mental retardation
t l t d ti
Wolters Kluwer‐Lippincott Williams and Wilkens
45. Cerebral Palsy
Classification
Spastic‐ (75%) increased tone (hypertonicity), rigid, poor
control of posture, balance and coordination, contractures
p , ,
Athetoid/Dyskinetic‐ (10‐15%) abnormal involuntary
movements‐ disappear during sleep, increase with stress
Ataxic‐ (5‐10%) wide‐based gait rapid repetitive movements
(5‐10%) wide‐based gait, rapid repetitive movements
performed poorly
Mixed Types
46. Cerebral Palsy
Accompanying health problems
h lh bl
Contractures
Pain
Feeding problems/ swallowing/ reflux/ nutrition
Respiratory problems
Dental disease
H i i i
Hearing impairment
Delayed Speech
Mental Retardation
Seizures
S i
Visual impairment (i.e. Strabismus)
Functional abilities to perform ADL's
Immobility
Wolters Kluwer‐Lippincott Williams and Wilkens
47. Cerebral Palsy
Management
** Early recognition is important so that optimum
development can be promoted‐ mobility it critical
p p y
Physical/ Occupational Therapy
Mobility Devices, AFO's (ankle foot orthotics)
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
Wolters Kluwer‐Lippincott Williams and Wilkens
48. Cerebral Palsy: Tendon Releases
Achilles Tendon Release:
After this surgery heals, the child may be
able to stand flat‐footed.
Femoral Osteotomy
50. 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
Often from a blow or jolt to the head
Sports injuries
p j
Kids are more susceptible to injuries than adults
Motor vehicle injuries
Falls
ll
Wolters Kluwer‐Lippincott Williams and Wilkens
51. Concussion signs
Concussion signs
Thinking/ Physical Emotional/ Sleep
Remembering Mood
Difficulty thinking Headache Irritability Sleeping more than
clearly usual
Fuzzy or blurry
vision
Feeling slowed Nausea or vomiting Sadness Sleep less than
down (early on) usual
Dizziness
Difficulty Sensitivity to noise More emotional Trouble falling
concentrating or light asleep
Balance problems
Difficulty Feeling tired, Nervousness or
g g
remembering new having no energygy y
anxiety
information
Wolters Kluwer‐Lippincott Williams and Wilkens
53. Return to play
A child with a concussion MUST NOT return to play
the same day
Sh ld b
Should be asymptomatic while at rest and with exertion
i hil d i h i
before return to play is considered
Closer monitoring during 1st 24‐48 hours after injury
24 48 hours after injury
Potential for more severe injury needing evaluation
Wolters Kluwer‐Lippincott Williams and Wilkens
54. Red Flags! Need to be evaluated
Looks very drowsy or cannot be awakened.
Unequal pupils
S 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
Infants/young children
Will not stop crying and cannot be consoled.
Will not nurse or eat.
www.cdc.ogv
55. Prevention of head injuries in
Prevention 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
56. Thank you
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