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M6 13-005

Exam 11: Cerebral Dysfunction in the Pediatric Patient

Cerebral Dysfunction: Types of measurement i. Newborn health and brain status ii. Intellectual disability iii. Hypoxic injury iv. Developmental milestones v. Level of consciousness
Refelexive Early neurologic responses in infants are primarily
Increased Intracranial Pressure (ICP) any increase in the three components located in the cranium that increases the total volume to greater than 100%.
cranium’s total volume made up of 80% brain, 10% cerebrospinal fluid (CSF), and 10% blood.
How does the body compensates to keep the total volumes equal? i. Reduced blood volume ii. Decrease in CSF production iii. Increase in CSF absorption iv. Brain mass shrinkage by displacement of intracellular and extracellular fluid
How do children with open fontanels compensate? skull expansion and widened sutures
Altered States of Consciousness Any change in the ability to respond to sensory stimuli and have subjective experiences (consciousness—awareness)
Components of Consciousness Alertness. Cognitive power.
Alertness an arousal-waking state, includes the ability to respond to stimuli
Cognitive Power the ability to process stimuli and produce verbal and motor responses
Unconciousness depressed cerebral function
purpose of the neurological examination establish an accurate, objective baseline of neurologic information.
Body temperature is often elevated and may be extreme i. Acute infectious process ii. Heat stroke iii. Ingestion of drugs iv. Intracranial bleeding v. Hypothalamic involvement (increased/decreased) vi. Coma from toxic ingestion may produce hypothermia
Hyperventilation is usually a result metabolic acidosis or abnormal stimulation of the respiratory center of the brain.
Periodic or irregular breathing is an ominous sign of brainstem dysfunction that often precedes complete apnea.
neurosurgical emergency The sudden appearance of fixed and dilated pupil(s)
Dilated and fixed pupils suggest paralysis of cranial nerve III secondary to pressure from herniation of the brain through the cranium, hypothermia, anorexia, ischemia, poisoning with atropine-like substances, mydriatic drugs.
Pinpoint pupils are commonly observed in poisoning (opiate, barbiturate) or in brainstem dysfunction.
Widely dilated and reactive pupils are often seen after seizures or eye trauma and may be only one side.
Unilateral fixed pupil suggests a lesion on the same side
If pupils fixed bilaterally for more than 5 minutes brainstem damage is usually implied.
Caloric Test or Oculovestibular response is elicited the child’s head elevated 30 degrees.
Papilledema characterized by i. optic disc edema ii. indistinct optic disc margins, iii. hemorrhage iv. tortuosity of vessels v. absence of venous pulsations
Flexion posturing signifies severe dysfunction of the cerebral cortex. a. Rigid flexion, arms held tightly to body b. Flexed elbows, wrists, and fingers c. Plantar flexed feet d. Legs extended and internally rotated e. Possible presence of fine tremors or intense stiffness f. Also known as decorticate posturing
Extension posturing is a sign of dysfunction at the level of the midbrain or lesions to the brainstem. a. Rigid extension and pronation of the arms and legs b. Flexed wrists and fingers c. Clenched jaw d. Extended neck e. Possibly arched back f. Also known as decerebrate posturing g. Cerebral dysfunction more severe than flexion posturing
absent in deep coma. The corneal, pupillary, muscle-stretch, superficial and plantar reflexes tend to be
severe brain damage Absence of corneal reflexes and presence of a tonic neck reflex are associated with
What is the Glasgow Coma Scale used for? It provides an objective measurement of levels of consciousness.
Explain what decerebrate positioning is and what it indicates. Decerebrate positioning is a sign of dysfunction at the midbrain characterized by rigid extension and pronation of the arms and legs. pROGRESION OF NEUROLOGICAL INSULT.
Emergency measures of the unconscious child are aimed toward ensuring a patent airway, treatment of shock, and decreasing ICP (if present).
aspiration and cardiac arrest Dysfunction of cranial nerves IX and X places the child at risk for
irreversible brain damage. Cerebral hypoxia lasting longer than 4 minutes nearly always causes
four types of ICP monitors i. Intraventricular catheter with fibroscopic sensors ii. Subarachnoid bolt (Richmond screw) iii. Epidural sensor iv. Anterior fontanel pressure monitor
Indications for inserting an ICP monitor are i. GCS evaluation of 8 ii. GCS evaluation of less than 8 with respiratory assistance iii. Deterioration of condition iv. Subjective judgment regarding clinical appearance and response
Nurses caring for patients with intracranial monitoring devices must i. Be acquainted with system used ii. Assist with the insertion iii. Interpret the monitor readings iv. Be able to distinguish between danger signals and mechanical dysfunction
Hyperthermia usually accompanies cerebral dysfunction
The three major causes of brain damage in childhood (in order of importance) Falls. MVAs. Bicycle Accidents. Big ol heads of infants.
Why are falls a major cause of brain damage in childhood? Because infants are frequently left unattended on beds, in high chairs, and other places from which they can fall. Incomplete motor development contributes to falls at young ages.
What age do bicycle injuries occur? Ages 5 to 19.
Who are at a greater risk for head trauma? Girls or boys? Why? Boys are affected twice as often as girls due to their propensity for greater risk-taking.
Most common head injury in children... Concussion.
hallmarks of concussion with children Confusion and amnesia following head injury
coup injury petechial hemorrhages along the superficial aspects of the brain at the site of impact
Contrecoup injury lesion remote from the site of direct trauma
Types of fractures Linear Fracture. Depressed Fractures. Comminuted Fracture. Basilar Fractures. Open Fractures. Diastaic Fractures.
Linear fractures the lines of the fracture are predetermined by the site and velocity of the impact and the strength of the bone. Uncommon before 2-3 years of age but constitute the majority of childhood skull fractures
Depressed fractures bone is locally broken usually into several irregular fragments that are pushed inward causing pressure on the brain. Uncommon before age 2-3 years. Infants & young children, skull may become dented in a peculiar rounded or “ping-pong ball” depression.
Comminuted fractures consists of multiple linear fractures which result from intense impact, may be from repeated blows against an object and may suggest child abuse.
Basilar fractures involve the basilar portion of the frontal, ethmoid, sphenoid, temporal, occipital bones. Because of the proximity of the fracture line to structures surrounding the brainstem, this is a serious head injury.
Signs and symptoms of Basilar Fractures include subcutaneous bleeding in the posterior neck area and over the mastoid process (battle sign), bleeding around the eyes (raccoon eyes), or bleeding behind the tympanic membrane (hemotympanum)
Open fractures communication between the skull and the scalp or the surfaces of the upper respiratory tract such as the paranasal sinuses or middle ear. Increased risk of CNS infection; facial paralysis, vertigo, tinnitus, or hearing loss may develop
Diastatic fractures traumatic separations of the cranial sutures, most frequently affect the lambdoid suture and are rarely seen beyond the first 3 years of life.
Complications of head injuries include Hemorrhage. Edema.
Epidural hemorrhage Blood accumulates between the dura and the skull to form a hematoma which forces the underlying brain contents downward and inward as the brain expands
Subdural Hemorrhage Blood accumulates between the dura and the cerebrum, usually as a result of rupture of cortical veins that cross over the subdural space. 10x more frequent than epidural hemorrhage.
Cerebral edema is caused by direct injury induces vascular stasis, anoxia and further vasodilatation.
Antiepileptics (Head trauma) used for seizure control and in cases of suspected contusion or laceration.
Antibiotics (Head Trauma) may be administered if there is any chance of infection
What are the potential complications of head injuries? Hemorrhage, infection, cerebral edema and brain herniation.
: What nursing intervention is most appropriate for a child with a head injury who is very restless and irritable? Provide analgesic as ordered
Near-drowning (Statistic) Major cause of accidental death in children of 1 year of age.
Near-drowning (definition) survival at least 24 hours after submersion in a fluid medium.
Problems caused by near-drowning Hypoxia. Acute Ventilator Insufficiency. Asphyxiation of fluid. Hypothermia.
For a child admitted for a near drowning, what is the priority nursing consideration? Respiratory support with attention to vital signs.
Brain tumor fact Brain tumors are the most common solid tumors in children and are the second most common childhood cancer.
The majority of brain tumors are infratentorial which means that they occur in the posterior third of the brain, primarily in the brainstem or cerebellum.
Other brain tumors are supratentorial or within the anterior two thirds of the brain, mainly the cerebrum.
Brain tumor: S/S (older children) Headache, especially on awakening. Vomiting that is not related to feeding. Occurs due to increased ICP, stimulating the vomiting center in the medulla.
Brain Tumor: Diagnostic Tests An MRI which determines the location and extent of the tumor. Other tests include CT, angiography, EEG, and lumbar puncture.
Why is temperature checks post-op brain surgery so important on child? important because of hyperthermia resulting from surgical intervention in the hypothalamus or brainstem and from some types of general anesthesia.
What are the most common signs and symptoms of a child with a brain tumor? The most common symptoms are: headache, especially on awakening and vomiting that is not related to feeding.
A child with a brain tumor is 4 hours postop. There is a small amount of clear drainage noted on her dressing. What do you suspect it is and what is the most appropriate thing for you, the LPN to do immediately? The presence of colorless drainage is reported immediately because it is most likely CSF from the incision area.
Therapeutic Management of Brain Tumor Surgery (treatment of choice). Radiation (Used to treat most tumors). Chemotherapy (keeps tumor at bay).
Nonobstructive or communicating Hydrocephalus a. impaired absorption of SCF fluid within the subarachnoid space b. obliteration of the subarachnoid cisterns c. Malfunction of the arachnoid villi
Obstructive or Noncommunicating Hydrocephalus obstruction to the flow of CSF through the ventricular system
What is the most common way that hydrocephalus is diagnosed in infants? Based on head circumference that crosses on or more gridlines on the growth chart within a period of 2 to 4 weeks.
What are the signs and symptoms of infection in a child that is 24 hours postoperative shunt revision? The signs and symptoms include: elevated vital signs, poor feeding, vomiting, decreased responsiveness, and seizures.
Created by: jtzuetrong