Exam 3: Neurology Flashcards
Head Trauma (2)
- Leading cause of death in children older than 1 yr. of age
* *Younger children are more prone to head trauma because they are top heavy
* *Top heavy: head is much larger in proportion to the rest of their body; puts them at risk for head trauma - 1 in 4 children will suffer head injuries serious enough for medical attention
* *Means you don’t need to go to the ER every time a pt. suffers head trauma
Disabilities that can occur second to Head Trauma (5)
- Developmental, gross motor, or cognitive delays
- Personality changes
* *Especially goes along with concussions - SIADH or other hormone changes
- Seizures
* *Head trauma is a cause of acquired epilepsy - ADHD
Etiology/Cause of Head Trauma (4 with common ages)
- Falls
* Number one cause in toddlers/younger children - Motor Vehicle Accidents
* Number one cause in teenagers - Bicycle injuries
* Number one cause in ages 6-15 years old
* Preventative measure is to wear a helmet! - Abuse
* Most likely in infants, “shaken baby syndrome”
Acceleration-Deceleration injuries
Acceleration: coup; the point of impact
*First injury suffered
Deceleration: counter-coup; the second point of impact where another injury can occur
*Second injury suffered
Third is shifting of brain contents; causes shearing and bleeding
- Bruising of the brain
Primary Head Injuries (info and 4 types)
A) Occurs at time of trauma; occurs at the time that you have the head injury
B) Most common primary head injury: concussion
- Other primary head injuries:
1. Fractures
2. Contusion and laceration (bruising and petechiae hemorrhage)
3. Hematoma/Intracranial hemorrhages
C) Pressure inside skull > arterial pressure
*This is what causes a loss of consciousness
D) Acceleration-deceleration is mechanism of injury
Concussion (with signs and symptoms)
Most common primary injury
Signs and Symptoms:
- CONFUSION AND AMNESIA!!
* This is the most common; amnesia and confusion at the time of head injury - Not always a LOC, but sometimes there is
Contusion and Laceration
A type of primary injury
- Contusion: bruising or petechial hemorrhage at the site of impact
- Laceration: very difficult to fracture skull, but if skull fracture occurs, a patient can suffer from a laceration
* *May have scalp hematoma that has a fracture underneath
* *Check for abuse if an infant comes in with this
Sites most affected by contusions
Occipital, frontal, and temporal lobes
Second Impact Syndrome
When you suffer a concussion before your initial concussion has subsided
**Many times the second impact is less than the initial one but second impact is very dangerous
- Rare condition that can have catastrophic results
- The brain loses its ability to auto regulate intracranial and cerebral perfusion pressure. This may lead to cerebral edema (severe swelling of the brain) and possible brain herniation
- Loss of consciousness after the initial injury followed by secondary brain damage creates ionic fluxes, acute metabolic changes, and cerebral blood flow alterations. All of these characteristics enhance the vulnerability of the brain and greatly increase the risk of death, even if the second injury was far less intense.
*Will use back-to-play timeline
Epidural Hemorrhage
- Bleeding between dura and skull
- Much more severe
- Rupture of an artery
- The changes that occur will be abrupt
- Seen less frequently than subdural hemorrhage/hematoma
Subdural Hemorrhage/Hematoma (6)
*When there is bleeding between the dura and the brain
- More common in children than epidural or cerebral hemorrhage
* *This is because IT IS A VEIN that ruptures, not an artery - May not occur right after the injury
* *Since it’s a vein, it can happen later - Acute subdural hemorrhage: occurs right after the injury
- Sub-acute subdural hemorrhage: can occur anywhere between 2-10 days after the initial injury
- Chronic subdural hemorrhage: occurs 10-21 days after initial injury
- Found in children with shaken-baby syndrome
Cerebral Edema
- Also can occur from fractures or any other type of primary head injury
- When there is cerebral swelling due to changes in cerebral bloodflow
- May not occur for 24-48 hours post head injury
Herniation through the tentorium
Herniation through the brain stem
Head Injury Complications Signs and Symptoms (7)
- Rapid change in LOC or personality change
* Especially in children - Change in gait
- Vomiting
- Drowsiness
- Pupillary changes
- Headache
- Seizures
* If a child has a significant head injury, parents should look out for these days after the injury
First things you do if child comes in with head injury (3)
- Stabilize spine
- Circulation, Airway, Breathing
- Evaluate for shock
Glasgow Coma Scale (5)
- Need to use the one specifically geared for children
- When doing Glasgow Coma Scale, you should have a calm parent there
- Evaluating: eye opening, verbal, and motor response
- If evaluating an infant, a good verbal response would be babbling or crying
- Lower score= higher of a concern
!!8 or below is concerning and indicative of coma!!
Pupillary Symmetry Concerns
If checking papillary symmetry and notice DILATED AND FIXED PUPILS, it is a neurosurgical emergency!!
Assessing Vital Signs after Head Injury (3)
- Patients with head injuries will have elevated temperature and HR
* *Tachycardia and Febrile - Pay close attention and assess RR
* *Look at rate, rhythm, pace, and effort of breathing
* *Look for any periods of apnea
* *Abnormal breathing pattern is a sign of brain stem involvement **!! - BP could go up or down
* *Blood loss could cause hypotension
* *Increased BP could be due to pain or anxiety
Cushing’s Triad
- Increase in systolic BP
- Widened pulse pressure (difference between systolic and diastolic)
- Bradycardia
- This is a late sign of increased ICP
- Periods of apnea may also accompany this
Occularvestibular response (5 things)
- Done to assess eye movements post head injury
- Will have the patient’s head elevated then place ice or cold water in ear
* You want to see eye’s deviate to the side where the ice was placed - Checking cranial nerves (6 and 3) are in tact and it also checks for any lower brain stem integrity
- Done for unconscious patient’s/patient’s in a coma
- CONTRAINDICATED IF patient has otitis media or ruptured TM !
Dolls Head Maneuver (3)
- When you turn a child’s head to the left, their eyes should go to the right and vice versa
* *Will have to hold the child’s eyes open while doing this - Checking CN 6 and 3 are in tact
- If you’re turning head to left and their eyes deviate to the left, it is not a good sign
Post Head Injury Fundiscopic Exam
Do it right away but may also want to check 24-48 hours after injury
- Very difficult to do in an awake, alert baby
- To get a good fundiscopic exam, it should be dark, the patient should be still, and you should give a child a point of focus so they don’t move around
- If checking the child’s left eye, hold the scope at your right eye; your right to their right (opposite side)
Post Head Injury Motor Function Assessment (5)
Checking:
- Spontaneous activity
- Posture
* *Posture changes can occur with significant neurological involvement - Response to painful stimuli
- Symmetry of movements
- Developmental milestones appropriate for age
* *Rolling, getting up on hands and knees, etc.
Decorticate Posturing
Indicates cerebral cortex problem
Deceribrate Posturing
Indicates mid-brain problem
Pupil Response Assessment Post Head Injury
Since some changes may not occur for 24-48 hours post head injury, may want to do a second fundoscopic exam after that time frame
- Things you are looking for in fundoscopic exam: signs of papilledema
- Also checking for pstosis
Signs of ICP in an Infant (9)
- Poor feeding
- Irritable or lethargic
- Bulging fontanel
* *Not the same as pulsating fontanel! Pulsating is normal - High pitched cry
- Increased head circumference
- Setting sun eyes
* *Can see it in patient’s with hydrocephalus
* *Looks like there is a sunset in someone’s eyes - Bulging scalp veins
- Widended head sutures
- Vomiting
Signs of ICP in a Child (7)
- Headache
- Diplopia (double vision)
- Mood swing
- Slurred speech
- Papilledema
- Altered LOC
- Nausea or vomiting
Papilledema Signs (6)
- Venous engorgement (usually the first signs)
* *Easy to see - Loss of venous pulsation
* *Easy to see - Hemorrhages over and / or adjacent to the optic disc
- Blurring of optic margins
* *Easy to see; means there is elevation - Elevation of optic disc
- Paton’s lines = radial retinal lines cascading from the optic disc
* *Difficult to see; will see little lines that look like water ripples
Management of Head Trauma: with NO LOC (3)
- Child checked q 2 hrs.
- Re-examined in 1-2 days by practitioner
- Child is aloud to go to sleep! They should be woken up every 2 hours to have their LOC assessed/assess any other signs of head injuries
Management of Head Trauma: with LOC
For LOC for more than a few minutes, seizures or neurological signs – admit to hospital
- *If there is LOC, a child should absolutely come in
- *If there is a change in neurological signs, LOC, and vomiting more than twice then child needs to come in to the ER immediately
Nursing Care for Head Injuries (11)
- Frequent VS and check for Cushing’s Triad
- Elevate HOB
- Avoid neck and spine compression (keep spine in line)
- Eliminate noise, no bright lights
- No suctioning or percussion
* *Could lead to vasovagal stimulation or increased pressure - NO Rectal Temperatures!
- NPO or clear liquids
- Use TYLENOL for fever
- Check nose drainage
- Incontinence of bowel or bladder
- Check for post-traumatic syndrome
Fluid Balance Post Head Injury
*Making sure not to overhydrate so that you don’t put patient at risk for cerebral edema
- Mannitol for cerebral edema
- Dextemethazone if there is inflammation
Nose Drainage Post Head Injury
*Want to make sure that the drainage is not CSF
- Check the glucose fluid (can use chem.-7 strip)
- If it’s clear discharge from a cold, it won’t have glucose in it
3 Pertinent info about Post-Traumatic Syndrome (and 10 signs and symptoms)
Signs and Symptoms:
- Drowsiness
- Dizzinness
- Headaches
- Difficulty concentrating
- Depression
- Pain changes
- Development of new phobias
- Difficulty sleeping
- Any major or noticeable behavior changes
- Seizures
A. Post-concussion syndrome can resolve usually within 2 weeks-6 months
B.If it is still occurring after a year, it most likely will not resolve
C. No specific treatment; will have to treat the symptoms individually
Seizures (4)
- Malfunction of brain’s electrical system resulting from abnormal discharge of neurons
- Manifestations are determined by site of origin
* *Symptoms can go along with where the area of the seizure occurs - 50% of childhood seizures are idiopathic
* May also be genetic or acquired - Use EMU to monitor seizure activity
* Parent can push a button if they think child is having a seizure so that clinicians can look at what was happening during that time
* Keep a diary to note if there have bee any triggers that cause the seizures
Reasons for Acquired Seizure (10)
- Infection (ex: meningitis)
- Fever can cause a seizure
- TBI can cause epilepsy
- Prematurity (which may be from intracranial bleeds)
- Hypoxia
- Traumatic delivery of infant
- Mother on drugs during pregnancy
- Metabolic diseases
- Brain tumors
- Taking Drugs
Epilepsy (5)
- Chronic seizure disorder with recurrent and unprovoked seizures
- Unprovoked: don’t know what causes it
- To be dx with epilepsy, need to have 2 or more unprovoked seizures
- Can be idiopathic or acquired; cause usually related to age
- Reticular formation in brain is affected; too much information getting to higher centers
Febrile Seizures (6)
- Usually occurs between 6 months - 3 years old
* *Unusual to see it in children over 5 years old - A generalized seizure that lasts under 5 min.
* *Generalized: it affects both sides of the brain - 30-40 % will have only 1 occurrence
* *But certain febrile seizures can have more than 1 occurrence - Unsure how high the fever goes or how fast the fever rises (height but not rapidity)
* *Some children have seized at 101 degrees, some can have 105 degrees and not seize - May be related to URI or GI infection
* *May see an underlying infection like this that can cause the high fever - 95% are benign and child will not go on to have epilepsy
Medications for Febrile Seizures
If patient has stopped seizing by the time they reach the ER, you don’t need to give any medications
*No maintenance medications; need to treat the underlying infection and/or give Tylenol for the fever
Partial Seizures
Occurs in Cerebral Cortex
Two different types: simple partial or complex partial
Simple Partial Seizure (5)
- No aura
- Motor signs
* *Tonic-clonic movements only on one side of the body
* *Occurs on the opposite side that the seizure is happening in - Sensory signs
A) Visual sensations
B) Tingling in extremities
C) May have accompanied smells or sounds
D) Happen during the seizure (dif. from aura) - No LOC
- No post-ictal state
Sensory Signs of Simple Partial Seizure (4)
- Visual sensations
- Tingling in extremities
- May have accompanied smells or sounds
- Happen during the seizure (dif. from aura)
Complex Partial Seizure (7)
- Has an aura; they know when the seizure is coming on
- Impaired consciousness (not total LOC)
- May be dazed/confused
- Automatisms
* *Repeated activity without purpose in a dreamy state
* *Ex: repeating a word over and over again, lip smacking, eye twitching - Ranges from minor to sever
- Can develop into generalized
- Postictal state (recovery time after a seizure)
* Doesn’t remember the seizure
* Very tired/exhausted
Generalized Seizure (7)
- Arise in reticular formation
- Affects both hemispheres
* Means they will have bilateral movement/how you tell it apart from a partial seizure - LOC frequent initial symptom
- No aura
- Movements are symmetrical
- BMR increased
* *Increase in metabolic rate, so patients are at risk for hypoxia during generalized seizures because of their increased need for oxygen !!!! - Postictal state (no recollection of seizure, very tired/exhausted)
Tonic-Clonic (Grand Mal Seizure)
~Type of generalized seizure
Two phases: tonic phase and clonic phase
1st: tonic phase
2nd: clonic phase
3rd: postictal state
Tonic Phase (6)
- Occurs first during tonic-clonic seizure
- Jerking of movements
- Generalized and symmetric contraction of body
- Apneic, may be cyanotic
- May have increased salivation
- Last about 10 – 20 seconds
Clonic Phase (6)
- Occurs second during tonic-clonic seizure
- Jerking movements with trunk and extremities having rhythmic contraction and relaxation
- Can’t control oral secretions
- Need to turn patient on their side to prevent aspirations!
- May be incontinent of urine and feces
- Can last from a few minutes to ½ hour or longer
Managing Seizure (4)
- Do not stick anything in patient’s mouth!!
- Make sure to time the seizure
* Anything >10 minutes is at risk for staticus epilepticus and then respiratory suppression and cardiac arrest - Do not lay or put anything on top of seizing patient
- Protect head and other body parts from injury
Post-Ictal State (8 signs and symptoms)
- Remain semiconscious and difficult to rouse
- May remain confused for several hours
- Mild impairment of fine motor movements
- May have vision and speech difficulties
- May vomit or complain of headache
- Usually sleeps for several hours (exhaustion)
- Complain of sore muscles
- Does not remember event
Absence Seizure (Petit Mal) (8)
- Type of generalized seizure
- Brief LOC
* *“Check out”
* *Mistaken for daydreaming, gets misdiagnosed - Onset is usually around 4 years old
- Can go into remission in adolescents
- More prevalent in females
- Usually has a genetic component associated
- May have 20 or more/day
- Brief LOC may be associated with lip smacking, twitching of eyelids
Atonic Seizure (6)
- Type of generalized seizure
- Will see child wearing a helmet if they have this
- Sudden or momentary loss of muscle tone
* *Could be mild where they have a head drop or could be severe enough that they fall to the ground
* *May have momentary LOC but then get up as if nothing happens
* *Risk for head injury which is why they wear the helmuts - Onset is ~2 years of age
- Can go into remission ~6 years old
- Can start weaning them off the medications if they have normal EEG and no symptoms for a period of time
Myoclonic Seizure (6)
- Type of generalized seizure
- Sudden, brief moment with jerking movements
- Usually occurs when falling asleep or when waking up
- Prevalent in school age and adolescents (later onset)
- No LOC or post-ictal state
- If patient is having sudden jerking motion, you can try moving head forward
* *If it s a child that is having normal changes when falling asleep, you’ll be able to move head forward
* *If it’s seizure activity, there will be resistance when trying to move the head forward
Infantile Spasms (8)
- Not a generalized seizure
- Infant is rigid, doesn’t really respond to the parent or interact with the parent
- Will have a significant developmental delay
- Can have 100+ seizures per day
- “Jack knife” type seizure
* *Contracting and extending - Eye rolling, tremors, posturing
- O2 saturation plummets; could be ~50s
- Usually diagnosed within first 3 months of life
Causes for Infantile Spasms
- Traumatic Delivery
2. Infant suffering from prolonged hypoxia
Infantile Spasm Remission
Usually occurs around 2 years old, children with significant underlying involvement will not go in to remission
*If no remission, around 2 years of age can transition to Lenox-Gastaut epilepsy, which is difficult to treat
Medication to Treat Infantile Spasms
- Vigabactrim
2. ACTH Hormone (IM administration by parent)
Interventions for Infantile Spasm (4)
- O2 (very important!!!)
- Yank-howsers oral suctioning (no deep suctioning)
- Make sure bed is padded
- IV fluids
Lab Tests for Dx Seizures
- Need full metabolic panel
* *Check electrolytes, blood sugar
* *Hypoglycemia can cause seizures
* *Checking for metabolic disorders - CBC to check for infection
- Toxicology screening
* Increased LED levels can cause seizures
Seizure Therapeutic Management: Medications (5)
- Medications are the first line treatment
* Commonly used: PHENOBARBITAL
* Also used: Kepur, Lamictal - If taking Phenobarbital, need calcium, vitamin D3 and folic acid supplements
- Always start out with monotherapy (just giving one medication)
* Complete control in 50-75% of affected children
* Dosage increased as child grows; otherwise could cause breakthrough surgery - If child is sick, parent needs to call neurologist because the child may need more or less dosage of the anti-convulsant
* For fever above 104, need increased dose - If 3 years without seizures, can start to withdrawal
Ketogenic Diet
- High fat
- Low carbs and sugars
- Low protein
- *Always want to ensure that the patient is spilling ketones
- *Good for younger infants on formula because they can create a specific formula with it
**Won’t be on the diet for a long time; tapered off by increasing protein and carbs in diet; this is done after a period of being seizure-free (~6 months)
**Generally not done with older children unless nothing else works
Indicators that a patient can be weaned off anti-seizure medications
- Seizure free for 3 years
* Compliance is important for this - Normal EEG for 3 years
- Must be a slow wean
* *At least 2 weeks or longer
* *Needs to be done at a non-stressful time
If you are seizure free for a year after coming off medication, there is a very low occurrence that you will start to get them again
Vagal Nerve Stimulator
Only used to treat complex partial seizures that haven’t responded to other treatments
*Must be 12 years or older to be a candidate
*When patient has an aura, they wave wand over a device that interferes with the seizure
