Cerebral Flashcards
1
Q
Cranium composition
A
80% brain
10% CSF
10% blood
2
Q
Major causes of Head injurys
A
Falls Motor vehicle injury Bicycle/motor bike Sports related injury Child abuse Assault
3
Q
TBI
A
Leads to severe brain damage or death if not recognized and treated appropriately
4
Q
Causes of ICP
A
Head injury Subdural/Epidural hematoma IVH (intraventricular hemorrhage) Fractures Meningitis/Encephalitis Hydrocephalus Status Epilepticus Reyes Syndrome Cerebral edema
5
Q
Concussion:
A
Most common injury
6
Q
Concussion: Hallmark signs and symptoms
A
Confusion, amnesia, altered neurological or cognitive function with or without loss of consciousness
Occurs immediately after injury
Signs of ICP
7
Q
Concussion: Treatment
A
Resolves between 7-10 days but can take up to several months depending on severity
Rest!!!
8
Q
Contusion
A
Visible bruising and tearing of cerebral tissue
Small petechiae or little bleeds in brain tissue
Degree of brain damage in the contused areas varies according to the extent of vascular injury
9
Q
Epidural Hemorrhage/Hematoma:
A
Bleeding the dura mater and the skull to form a hematoma, dura is peeled off the skull, and its arterial blood that lying underneath
Not as common as subdural hematomas
Usually occurs in younger adults
10
Q
Epidural Hemorrhage/Hematoma: S/S
A
Brief loss of consciousness followed by a period of awareness that may last several hours before the brain function deteriorates sometimes leaving the patient in acoma
Very serious if not treated immediately the patient can die
11
Q
Epidural Hemorrhage/Hematoma: Treatment
A
Neurosurgeon will go in and evacuate the hematoma
Patients usually have a good outcome if its recognized immediately
12
Q
Subdural Hemorrhage
A
Bleeding between the dura mater and the arachnoid membrane, usually due to stretching and tearing of veins on the brain’s surface
Traumatic, acute subdural hematoma is the most lethal of all head injuries
More common than epidural hematomas. most often infancy as a result of birth trauma, falls, child abuse, or violent shaking
13
Q
CSF analysis: Glucose content-viral
A
Normal
14
Q
Penetrating trauma
A
Gun shot wounds or objects that break the barrier of the skull
15
Q
Fractures: Linear
A
Most common type of skull fracture
break in the bone but it doesn’t move the bone
May be observed for a brief time
No interventions needed
16
Q
Fractures: Depressed
A
Seen with and without a cut in the scalp
Part of the skull is actually sunken in from the trauma
May require surgical intervention, depending on the severity, to help correct the deformity
17
Q
Fractures: Diastatic
A
Widen the sutures of the skull and usually affect children under 3
The normal suture lines are widened
More often seen in newborns and older infants
18
Q
Fractures: Comminuted
A
Fracture in which the bone has broken into several pieces
19
Q
Fractures: Basilar
A
Most serious type of skull fracture, and involves a break in the bone at the base of the skull
Frequently have bruises behind the ears (battle signs) and around the eyes (raccoon eyes)
Clear fluid draining from their nose or ears due to a tear in part of the covering of the brain
Usually require close observation in the hospital
Classic raccoon eyes, bleeding around the nose, ear, and ethmoid sinus
20
Q
Minor head injury symptoms
A
May or may not lose consciousness HA Confusion, amnesia Listlessness Pallor Vomiting, generally projectile Irritability Seizures
21
Q
Severe head injury symptoms
A
Decreased LOC/GCS Changes in VS Bulging fontanels Retinal hemorrhage Unsteady gait Hemiparesis, numbness on one side Quadriplegia, numbness on all 4 extremities Elevated temperature
22
Q
Warning signs after head injury (first 24hr)
A
Change in LOC Increased drowsiness, confusion, difficult to arouse Seizures Bleeding or water drainage from nose and ears Pupils slow to react or unequal Visual problems Loss of sensation to any extremity Slurred speech Projectile vomiting
23
Q
Diagnostics for head injury
A
H&P Baseline VS SpO2 LOC/GCS ABG Alcohol level Drug screen CBC Xray CT scan MRI
24
Q
Secondary complications from head injury
A
Changes in LOC (Pay attention to changes) Coma Increased ICP Infection -open penetrating wound Cerebral edema Hemorrhage Seizures Hypoxic brain damage Brain herniation Brain death
25
Nursing management of head injury
```
ABC
Cervical spinal cord stabilization (neck brace has to stay in place until cervical spine injury has been ruled out)
Elevate HOB and Midline
Thorough PE (log roll patient)
VS (look for widening pulse pressure and low pulse- sign of Cushing's triad)
SpO2
GCS
Pain
Drainage (eyes, ears, nose)
NPO
IV fluids
Strict I & O
Monitor labs closely (Na, serum osmolality, urine output, DI, SIADH)
Seizure precautions
Monitor S/S of ICP (complaining of HA, pupillary changes, vomiting, behavioral changes)
Quiet, dark room, Cluster care
Support family and educate
```
26
Glascow coma scale: Eye opening
4: Spontaneously
3: To voice
2: To pain
1: None
27
Glascow coma scale: Verbal response
5: Normal conversation
4: Disoriented conversation
3: Words, not coherent
2: No words, only sounds
1: None
28
Glascow coma scale: Motor response
6: Normal
5: Localized to pain
4: Withdraws to pain
3: Decorticate
2: Decerebrate
1: None
29
GCS classifications
Mild: 13-14
Moderate: 9-12
Severe: 3-8
30
Leaking of CSF
Halo sign on the sheets
There is blood at the center surrounded by clear liquid leaking and a visible ring surrounding
Use a chemical strip and dip it for glucose
Positive: its CSF
31
Increased intracranial pressure (ICP)
Increase in volume of the cranium leads to increases intracranial pressure
Infants can compensate when sutures are still open
Changes in LOC is the first sign of ICP
Changes in vital signs follow: Cushing triad (late sign)
32
Causes of Increased ICP
```
Head injury
Subdural/Epidural hematoma
IVH (intraventricular hemorrhage)
Fractures
Meningitis/Encephalitis
Hydrocephalus
Status Epilepticus
Reyes Syndrome
Cerebral edema
```
33
Signs of Increased ICP: Infants
```
Tense bulging fontanel
Separated cranial sutures
Increased FOC
Irritability
Restlessness
Drowsiness
Increased sleeping
Poor feeding
High pitch cry
```
34
Signs of Increased ICP: Children
```
HA
N/V
Diplopia
Blurred vision
Seizures
Drowsiness
Lethargy
Increased sleeping
```
35
Severe/ Late signs of Increased ICP: Changes in LOC
Decreased response to painful stimuli
Decreased consciousness
Coma
Seizures
36
Severe/ Late signs of Increased ICP: Eyes
Changes are considered a medical emergency (notify MD immediately)
Papilledema (bulging or swelling behind optic disc that is caused by increased ICP, usually bilaterally and can occur occur a period of hours to weeks)
Alterations in/unequal pupil size and reactivity to light (fixed or dilated pupil)
Impaired eye movement
37
Severe/ Late signs of Increased ICP: Posturing
Decerebrate
Decorticate
Flaccid
38
Decerebrate
Arms are extended outward, indicative of severe brain stem injury
Worst posturing
39
Decorticate
Abnormal posturing where person is stiff with arms bent, clenching fist with legs pointed out straight
Mummy pose
Severe brain damage
40
Severe/ Late signs of Increased ICP: Change in vitals
Cushing's triad
Cheynes-stokes respirations (increased RR, then slow RR, then a period of apnea)
Decreased motor response to command
41
Management of Increased ICP
```
Neurosurgery consult
Emergency craniotomy
Mechanical ventilation
Central line/Arterial line
CPP (cerebral perfusion pressure)=MAP (represents the pressure gradient driving cerebral blood flow and hence O2 and metabolite delivery)
NGT/DHT
Foley
ICP monitoring (EVD, Bolt, Normal pressure ranges from 3-5, sneeze goes up to 10-15)
High ICP must be treated immediately
```
42
Nursing management of Increased ICP
```
Monitoring
Strict bed rest
NPO/IV fluids
Strict I&O
Pain control
Elevate HOB
Head midline
Decrease stimuli
Cluster care
Suctioning
Restraints
Elimination
Safety
Nutrition
Seizure precautions
Coping
```
43
Diabetes insipidus
```
High urinary output
Low level of ADH
HyperNa
Dehydrated
Lose too much fluid
Excessive thirst
```
44
SIADH
```
Low urinary output
High ADH
HypoNa
Overhydrated
Retain too much fluid
Excessive thirst
```
45
Pharmacological management of Increased ICP
```
Mannitol (cerebral edema)
Hypertonic saline solution (preferred)
Corticosteroids
Analgesics
Sedatives
Paralytics
Anticonvulsants (prophylactic)
Antibiotics
```
46
Reportable S/S of Increased ICP
Change in: V/S, labs, LOC, GCS, Behavior, Pupils, Pain, Posturing
47
Confirmation of brain death
Fixed and dilated pupils
Absent corneal reflexes (rub q-tip across cornea)
Absent gag reflex
Apnea test (turn off ventilator for 30 sec and see if the patient breaths)
Cold caloric test (put water in the patient's ear- causes nausea, nystagmus)
EEG (cerebral silence)
Cerebral blood flow exam/No flow to the brain
48
Prevention of head injury
Never leave infant unattended on bed, couch, chairs
Always have infant/child secure in high chair
Always have infant/child in appropriate size car seat, secure seatbelt
Place car seat in appropriate position in regards to age/wt/manufactures recommendations
Firearm security and safety
Make sure helmets are worn during bike ride/horseback riding/skating/skateboarding/sports
Monitor child's play on playgrounds and around roads/stairs/steps
Never shake a child
49
Cushing's triad
HTN
Bradycardia
Apnea
50
Intracranial infections
Meningitis (inflammation of the meninges lining the brain and the spinal cord)
Encephalitis (inflammation affecting the brain)
51
Meningitis: Viral or Aseptic: Caused by
Viral illnesses (mumps, measles, herpes, CMV, adenovirus, HIV)
52
Meningitis: Viral or Aseptic
Short lived, self limiting, complete recovery
| Occurs most often in very young children <2mo
53
Meningitis: Viral or Aseptic: Manifestations
Generalized rash but wont have a purpuric or petechial rash that you see in bacterial meningitis
54
Meningitis: Viral or Aseptic: Treatment
Give Tylenol or Ibuprofen if they complain of HA or body aches and to control their temp
Keep comfortable, the virus has to run its course
55
Meningitis: Bacterial or Septic: Caused by
Pus forming bacteria
Group B Strep, E. coli, L. monocytogenes: <2mo old
S.pneumoniae, N. meningitidis: >2 mo old
Meningococcal meningitis: School age, adolescents, college students
56
Vaccines that have lead to a decline in meningitis
H. influenzae type B (Hib)- 2,4,6 months and between 12-18 months
Pneumococcal conjugate vaccine- 2,4,6 months and between 12-18 months
Meningococcal conjugate vaccine- given between 11-18 years with a booster 5 years later
57
Bacterial Meningitis: Symptoms in Neonates
Refusing feedings or poor sucklig ablility
Vomiting or Diarrhea
Poor or weak muscle tone and lack of movement
Weak cry
Full/tense bulging fontanel
58
Bacterial Meningitis: Symptoms in infants and young children
```
Bulging fontanelle
High pitch cry
Vomiting
Refusing food
Stiff or rigid neck
Fast shallow breathing
Skin rash
Very irritable
Extreme shivering
Floppy limbs
Cold hands and feet
Seizures
High or low temp
Lethargic
Photophobia
```
59
Bacterial Meningitis: Symptoms in children and adolescents
```
Usually abrupt onset
Fever
Chills
HA
Vomiting
Seizures
Agitation
Nuchal rigidity
May develop: photophobia, delirium, stupor, hallucinations, drowsiness, coma
```
60
Nuchal rigidity
Resistance to neck flexion due to meningeal irritation
| Positive Kernig and Brudzinski sign
61
Kernig sign
Patient supine, with hip flexed 90 degrees, knee cannot be fully extended
62
Brudzinski sign
Neck rigidity
| Passive flexion of neck causes both flexion of both legs and thighs
63
Meningitis: Diagnostics
```
Physical assessment; Head to toe
Lumbar puncture (definitive)
CT scan (rule out other abnormalities)
Blood culture (rule out infections)
```
64
Lumbar puncture
Patient is bent over to open spaces between. vertebrae
Explain to the patient and family what to expect after
Use Elma cream on L4-5 or L3-6, and let it stay on for 30 minutes
Lie still for several hours after procedure to prevent HA or a CSF leak
65
CSF analysis: WBC count: bacterial
Elevated, increased polymorphonuclear leukocytes
66
CSF analysis: WBC count: Viral
Slightly elevated, increased lymphs
67
CSF analysis: Protein count: Bacterial
Elevated
68
CSF analysis: Protein count: Viral
Normal or slightly increased
69
CSF analysis: Glucose content: Bacterial
Decreased
70
CSF analysis: Glucose content: Viral
Normal
71
CSF analysis: Gram stain: Bacterial
Postive
72
CSF analysis: Gram stain: Viral
Negative
73
CSF analysis: Color: Bacterial
Cloudy
74
CSF analysis: Color: viral
Clear
75
Meningitis: Nursing Alert
Major priority with a child suspected of having meningitis
1. Initiate contact and respiratory isolation precautions immediately
2. Initiate antibiotics as soon as they are prescribed by physician. Child is places on respiratory isolation for at least 24 hr after initiation of antibiotics and C&S results are confirmed
Need to give antibiotics with in 30 minutes
76
Bacterial Meningitis: Management
```
Isolation precautions
Initiation of antibiotics with in 20 minutes of patients arrival, suspecting meningitis
Restrict hydration initially
Maintenance of ventilation - ABCs
Reduction of increased ICP
Management of systemic shock
Control seizures
Control temp
```
77
Bacterial Meningitis: Nursing management
```
ABCs
Cardiopulmonary monitoring
IV placement (long term- big veins)
ABX at least 7-10 days so possible PICC line placement
Strict I&Os
Quiet room
Cluster care
Elevate HOB
Pain control
```
78
Bacterial Meningitis: Education
Exposed family need to take Rifampin
Long term antibiotics needed for at least 10 days
Hearing loss is common due to ototoxicity from high dose of antibiotics and from having meningitis itself
Auditory evaluation 6 months after the illness has resolved
79
Seizures
Result of uncontrolled electrical discharge from nerve cells to the cerebral cortex
80
Seizures: characterized by
Sudden brief attacks of altered consciousness, motor activity, and sensory phenomena
81
Seizures: Associated with
Variety of verbal and systemic disorders such as a focal or generalized disturbance of cortical function
82
Seizures: Sensory symptoms
Arise in the parietal lobe
83
Seizures: Motor symptoms
Arise in the frontal lobe
84
Seizures: Risk factors
```
Genetics
Feve
Head trauma
Infections
Noncompliance with medications
Stress
Tumor
Withdrawal
Fluid and electrolyte imbalance
Flashing lights or video games
Toxin or chemical exposure
```
85
Febrile seizures
Most common neurological condition of childhood
Affects children between the ages of 6mo-5 yr
Occurs with a fever above 38.0C
Use tylenol or ibuprofen to make child more comfortable
Recurrence is common
86
Febrile seizures: Parental reassurance
It will stop on its own, does not cause any other health problems, place the child on their side or stomach
Time seizure, if it last longer than 10 minutes take them to the ER
Once seizure has ended take child to provider to check the source of the fever, this is urgent if the child is showing signs of stiff neck, extremely lethargic, continued vomiting- signs of meningitis
87
Febrile seizures: Signs
```
Jerky movement
Convulsions
Shaking
Twitching
Moaning
May become unconscious
```
88
Seizure: Treatment options
Antiepileptic drugs
Ketogenic diet
Vagus nerve stimulation
Surgical management
89
Seizure: Antiepileptic drugs
```
Fosphenytoin
Phenytoin
Diazepam
Lorazepam
Gabapentin
Cerebyx
Tegretol
```
90
Seizure: Ketogenic Diet
Hight fat, low CHO and adequate protein that puts them in a state of ketosis and studies have shown that as many as 50% of children on this diet will have a decrease in seizures
91
Seizure: Vagus nerve stimulation
Performed under general anesthesia, where a device is implanted into left chest wall and is connected to an electrode placed at left vagus nerve
Its programed to administer intermittent vagal nerve stimulation by holding a magnet over the implanted device at the onset of seizure activity. This will either abort the seizure or lessen its severity
92
Seizure: Surgical management
In certain situations it may be needed, like a corpus colostomy, or depending on severity of seizures, how often they are having them...
93
Seizure: Nursing management
```
Side rails up
Bed in the lowest position
Padded side rails
Call light within reach
Waterproof mattress
O2 and suction at bedside
Medical ID bracelet for seizure and fall precautions
```
94
What to do when pt is having seizure
```
Remain calm
Time the seizure
Position the child for safety (side laying)
Prepare to suction any oral secretions
Maintain airway
Loosen clothing
Never restrain
Never attempt to open their jaw or insert an airway during seizure activity
Place pillow under head
Ensure safe environment
Stay with the child and reassure until fully awake
Notify MD
Document S/S
```
95
What to do after seizure
Stay with them until they are fully awake
CHeck VS
Keep them in side lying to prevent aspiration and facilitate drainage of oral secretions
Assess for any injuries and perform neurological checks
Allow the child to rest, they will be sleepy in the postictal state
Reorient them and calm them
Encourage them to describe the period before, during and after seizure activity, experience aura? trigger?
Document s/s, onset, duration, apnea, cyanosis, LOC, incontinent
96
Seizure: When to call for Dr./RR
```
Evidence of injury after seizure
Pt has DM
Pt is pregnant
Seizure last >5 min
Pupils are not equal after seizure
Child vomits continuously 30 min after the end of seizure
Seizure occurred in water
Pt first seizure
Status epilepticus occurs
```
97
Seizure: Call code/start CPR
Patient is unresponsive, stops breathing, barely breathing, gasping with <10 breaths/min
Patients heart stops beating or less than 60 beats/min with signs of poor perfusion
98
Seizure: Care management
Nurses are responsible for observing the seizure episode and accurately document the events, not diagnosing the type
Only describe what happened
Note the duration with a start and stop time
99
Seizure: Goals of Care
Control the seizures or reduce their frequency and severity
Discover and correct the cause when possible
Help the child live as normal as possible
If child has a history, ask them if they have an aura before an episode. This will let you/them know what to look for so you can protect them for harm/implement precautions
100
Status Epilepticus
Continuous seizure lasting more than 30 min, or 2 or more seizures without full recovery of consciousness between any of them
Requires immediate treatment to prevent loss of brain function, which may become permanent, because the brain isn't getting the blood/O2 flow it needs
101
Status Epilepticus: Nursing management
```
ABCs
Monitor VS
Continuously monitor SpO2 and ABGs
Administer O2
Obtain IV, preferably a central line because many antiepileptic drugs can be caustic to the vein
Perform a stat EEG
Intubation
Sedation
Give loading dose of Lorazepam or Diazepam followed by continuous infusion of Phenytoin
```
102
Hydrocephalus
Imbalance in the production and absorption of CSF in the ventricular system
Ventricles become dilated and compress the brain against the cranium, causing an increased ICP
103
Hydrocephalus: Causes
```
Tumor
Hemorrhage
Infection
Congenital malformations
Trauma
```
104
Hydrocephalus: Clinical manifestations: Infants
```
Large head
Widened sutures
Rapidly increasing FOC
Full and bulging fontanels
Irritability
Vomiting
High pitched cry
Poor feeding
Sun-setting sign
Sluggish pupils
```
105
Sun-setting sign
Sclera showing at top eyelid, eyes depressed and rotated downward due to the increased pressure in the brain
106
Hydrocephalus: Diagnostics
FOC- crosses the 1% line on the FOC chart with in 2-4 weeks 🚩
CT scan
MRI
Any clinical manifestations
107
Hydrocephalus: Therapeutic management
Placement of a VP or a VA shunt in the ventricle and threading it into either the right atrium of the heart or the peritoneal cavity of the abdomen
108
Hydrocephalus: Post-op nursing care
```
Positioning: initially supine for the first 12 hr, can also be placed on their side if that's comfortable, make sure its t the uncooperative side. Slowly start elevating the HOB
Pain management
Monitor VS
GCS
Skin integrity at insertion site, in their heart/chest area (if catheter is threaded to their abdomen: assess that area for signs of redness, swelling, drainage, tenderness, and distention)
Signs of infection
Signs of malfunction
Educate/prepare for DC
```
109
Hydrocephalus: Signs of Shunt malfunction
Signs of increased ICP because the valve gets kinked, then drainage is backing up in the brain
110
Hydrocephalus: Complications: Shunt infection
Greatest risk is 4-8wk after placement
Meningitis
Ventriculitis (inflammation of the ventricles where the shunt was placed)
Remove shunt: get culture to know how to treat
Antibiotics: 7-10 days (PICC line preferred)
111
Hydrocephalus: Complications: Shunt malfunction
```
Kinking
Plugging
Separation or migration of tubing
Mechanical obstruction
Remove shunt
Replace shunt
```
112
Hydrocephalus: External ventricular device (EVD)
If patient does have to have their shunt removed, they may have had an EVD to drain the fluid until the shunt is replaced.
This allows you to obtain cultures from the CSF
You can regulate the amount of drainage you're getting from the patient
Pay attention to patients position because if they move, you have to adjust your EVD, because it impacts the amount of drainage coming out
113
Hydrocephalus: EVD: Nursing management
```
Must be knowledgeable about the equipment
Assist MD in insertion
Set up and replace equipment
Maintain placement level
Draw samples from port
Interpret and monitor readings
Document assessment findings
Notify MD of changes/problems
```
114
Hydrocephalus: EVD: Notify MD if..
Change in color, amount of CSF drainage
Behavioral changes
Signs of infection at EVD insertion site
115
Reyes syndrome
Extremely rare but serious illness that can affect the brain and liver
Most commonly in children recovering from viral infection
Occurs more in winter months when there's been an outbreak of chickenpox or influenza B
Duration of illness depends on the severity of the disease
5 Stages (mild and self limiting-rarely death within hours)
Early recognition and treatment are imperative
Treat as medical emergency
116
Reyes syndrome: Etiology
Still not well understood, and there's no cure for it.
Just has to run its course
Treatment is systemic depending on the stage
Linked to aspirin/salicylates or aspirin containing medication during viral disease as a factor in development
117
Reyes syndrome: Diagnosis
No specific test
Screening starts with blood, urine tests, testing fatty acid oxidation disorders and other metabolic disorders
More invasive diagnostic tests are needed to evaluate other possible causes of liver problems and to investigate any neurological abnormalities (spinal tap, liver biopsy, CT scan, MRI, Skin biopsy may be done for FA oxidation or metabolic disorders)
118
Reyes syndrome: Signs and Symptoms
```
Frequent vomiting
Lethargy, sleepiness
Irritability or aggressive behavior
Infants: Diarrhea, rapid breathing
Changes in vision
Difficulty hearing
Abnormal speech
Alteration in LOC
Fatty liver changes
Hepatomegaly
Severe muscle weakness
Seizures
Loss of consciousness
```
119
Reyes syndrome: Management
Supportive or symptomatic depending on the stage- NO cure
ABCs
Prepare patient and family for diagnostic tests
Monitor VS (continuous cardio-pulmonary)
Strict I&Os
Monitor for signs of /Control ICP (at risk for increased ICP want to give osmotic diuretic)
Implement seizure precautions (at risk for seizure: put on prophylactic medication)
Monitor lab studies (put them on vit. K, might also receive plasma and platelets due to bleeding from the live abnormalities, so pay close attention to PT, aPTT, INR)
Nutrition support
Monitor fluid and electrolyte and liver function tests
120
Reyes syndrome: Stage 1
```
Vomiting
Lab evidence of liver dysfunction
lethargic
Sleepy
(Mild-moderate)
```
121
Reyes syndrome: Stage 2
```
Deeply lethargic
Restlessness
Confused
Delirious
Combative
Hyperventilation
Hyperreflexia
(Mild-moderate)
```
122
Reyes syndrome: Stage 3
Obtunded or in a light coma
Decorticate rigidity
(Mild-moderate)
123
Reyes syndrome: Stage 4
```
Deepening coma
Seizures
Decerebrate rigidity
Fixed pupils
Loss of oculovestibular reflexes
(severe)
```
124
Reyes syndrome: Stage 5
```
Seizures
Deep coma
Flaccid paralysis
Absent deep tendon reflexes
Respiratory arrest
Fixed and dilated pupils
(Severe)
```
125
Reyes syndrome: Family support and education
Many OTC medications contain Salicylates
Aspirin should not be used for kids or teenagers except on the advice of the Dr for certain conditions because it can cause severe brain and liver damage
NO ASPIRIN OR ASPIRIN CONTAINING MEDICATIONS TO CHILDREN OR ADOLESCENTS!!
