Peds neuro

Injuries in children
 Unintentional injuries are the leading cause of death
in children 0‐19 years
 #1 cause overall‐ MVC
ll
 Occupants
 Pedestrians and pedestrian cyclists
p y

Wolters Kluwer‐Lippincott Williams and Wilkens

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


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 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


Anatomic differences
Anatomic differences
 Head is large in proportion to body
 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 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


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

Neuro HPI
 Nausea/vomiting
 Vision changes
 HA/photophobia
HA/ h t h bi
 Neck stiffness
 Poor feeding
 Inconsolability
 Lethargy
gy
 Fever
 Ataxia
 Trauma history

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


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


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”


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


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


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


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


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‐


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


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
 Catheter
PPumping chamber
i h b
 One way valve
 Distal catheter


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


The Neural Tube

 Neural Tube Defect:
l b D f
 Example: Myelomeningocele
 “Spina Bifida”
Spina Bifida

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


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


Seizures
 Occur in approximately 10% of children
 Fever, infection, trauma, hypoxia, toxins, cardiac
arrhythmia s
arrhythmia’s
 Familial tendency
 Unknown cause


Seizures
 Two major categories
 Partial‐ large proportion of childhood seizures
 Simple
l
 Complex
 Generalized


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.


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


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


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


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.


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


Grid Placement Surgery:
Identify Locality of Seizure
Activity

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

Bacterial Meningitis
 Infection of the meninges, the lining the surrounds
the brain and spinal cord
 C l d b i d
Can lead to brain damage, stroke, deafness, stroke and
k d f k d
death
 Decreased dramatically due to HIB vaccine in US

 Deterioration can be rapid
p
 Need prompt IV antibiotics
 Lumbar puncture/blood cultures/CBC


Signs
 In older children
 Neck stiffness,
headache, fever
h d h f
 Babies/young children
 Opisthotonic position
 Bulging fontanelle
 Inconsolable
 Rash


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.

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


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

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


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


Cerebral Palsy: Tendon Releases

 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
 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

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


Concussion symptoms
 May or may not have loss of consciousness
 CT scan and MRI are normal, as it does not result in
structural damage to the brain
l d h b i


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


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

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

Thank you


Peds neuro

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