Peds - Exam 3 - Neuro Flashcards
Levels of consciousness in descending order
Full consciousness
Confusion—impaired decision making
Disorientation—to time and place
Lethargy—sluggish speech
Obtundation—arouses with stimulation
Stupor—responds only to vigorous and repeated stimulation
Coma—no motor or verbal response to noxious stimuli
Persistent vegetative state—permanently lost function of cerebral cortex
Increased ICP - Clinical Manifestations in Children
Headache
Vomiting—with or without nausea (projectile)
Seizures
Diplopia, blurred vision
Increased ICP - Clinical manifestations in infants
Irritability, poor feeding High-pitched cry, difficult to soothe Fontanels—tense, bulging Cranial sutures—separated Eyes—setting-sun sign (eyes bilaterally deviate downward) Scalp veins—distended
Late signs of increasing ICP
Decreased LOC
Decreased motor response to command
Decreased sensory response to painful stimuli – really late sign
Alterations in pupil size and reactivity
Papilledema – swelling to optic disc
Decerebrate or decorticate posturing
Cheyne-Stokes respirations – periods of fast breaths and apnea – look at video posted with lecture
Seizure vs. Epilepsy
Seizure
A single seizure not generally classified as epileptic
Single seizure not generally treated with long-term Rx
Will resolve once medical condition is resolved
Epilepsy
Condition characterized by two or more unprovoked seizures
Multiple causes by a variety of pathologic problems in the brain
Behavioral signs of increasing ICP
Irritability, restlessness
Drowsiness***, indifference, decrease in physical activity and motor skills
Complaint of fatigue, somnolence
Inability to follow commands, memory loss
Weight loss
What to note when assessing pupil size
Medications can affect - important to know what medications that patient is on
Size of pupils, whether they are reactive - large pupils may be normal if they are reactive
Bilateral fixed pupils for longer than 5 mins usually indicates brainstem damage
One pupil dilated and fixed –
Bleed or lesion on same side of brain
Neurosurgical emergency - should be reported immediately!
Doll’s Head Maneuver
ONLY perform this after a spinal cord injury is ruled out!
- Rotate child’s head quickly from one side to the other
- Positive - brainstem intact, eyes move in opposite direction of head (normal reaction)
- Negative - eyes are remaining in fixed position no matter where head is being moved, brainstem dysfunction or damage to CN III (oculomotor)
Caloric test
Used to assess brain death in child
** Never going to be performed on an awake/conscious child
Very painful
Irrigate auditory canal over 20 seconds with ice cold water
HOB elevated 30 degrees
Normal response—eyes move toward the side of stimulation.
Abnormal response—no response
Very precise procedure, physician likely performing, nurse assisting
Decorticate/Decerebrate Positioning
Posturing may only be present with painful stimuli
Neither type of posturing is good
Ideal response – patient would withdraw
Decorticate – flexion – bringing it into the CORE
- Occurs with severe dysfunction of cerebral cortex or lesions above the brainstem
Decerebate – extension of extremities
- Occurs with dysfunction at level of midbrain or damage to brainstem
CT or MRI considerations
Most kids will need to be sedated for them - not because it’s painful
But just can be really hard for the child to lay still, especially for an MRI
Nurse or parent may be present in room (behind window) to comfort child, if facility permits
Signs of pain in comatose patient
- Tachycardia
- Increased respiration
- Increased BP
- Sats drop
(Pain can also increase ICP, so try not to do things to increase pain)
Drug therapies for pain in comatose child
Opioids – morphine or dilaudid
Fentanyl (opioid) + midazolam (versed – short-acting, causes amnesia) + vecuronium (paralytic, neuromuscular blocker, frequently used in pediatric pts who are intubated)
Acetaminophen and codeine – comfort measures
Comatose child - respiratory management
- Airway management is primary concern
- Cerebral hypoxia lasting more than 4 minutes will likely cause irreversible brain damage
- CO2 causes vasodilation, increased cerebral blood flow, and increased ICP
- May have minimal gag and cough reflexes
- Risk of aspiration of secretions
*** periodic or irregular breathing is an ominous sign – usually indicates brain stem is affected – often see prior to death with head injury
Indications for ICP monitoring
Glasgow Coma Scale score 8 with respiratory assistance
Deteriorating neurologic condition
Subjective judgment
Subarachnoid bolt
- Most frequently seen
- Scary looking for parents
- Place bolt directly to the ventricles – monitors ICP
- Held intact by dressings on the outside
- Need to be VERY careful around it – only neurosurgeon should touch it
- Nurses don’t even touch the dressing to assess the site
Nursing care for child with increased ICP
Patient positioning
- HOB 15-30 degrees
- Head should be maintained midline ideally
- Avoid frequently turning head
Avoid doing things that increase ICP
- Pain
- Too much stimuli
- Avoid doing things that will make a child cry
- ROM exercises still done but GENTLY
Suctioning issues
- Usually poorly tolerated
- May need to do because of loss of gag reflex –> will have to suction
- Really GENTLE suction & hyperoxygenate beforehand
Nutrition and Hydration
- Avoid overhydration – strict I&O – to avoid cerebral edema
- IV fluids and TPN and lipids or gastric feedings
Comatose patient - nursing care needs
- Elimination – will always have foley initially, need to record BMs (may require stool softeners as needed)
Hygienic care – skin integrity and good mouth care
- Emollients to lips – often very dry
- Eye drops/ointments
- Position and exercise
Stimulation
- Hearing is last sense to go – may be capable of hearing/sensing – still going to explain what you are doing
- Encourage family to talk with patient
- Soft music
Family support
Concussions
- transient and reversible
- Results from trauma to the head
- Instantaneous loss of awareness and responsiveness lasting for minutes to hours – DONT always have to lose consciousness for it to be concussion
- Can have nausea and vomiting afterwards
- Generally followed by amnesia and confusion
Post concussion syndrome
- Headache, dizziness, fatigue, irritability, issues with concentration or memory impairment
- Usually develop the day of injury and last up to 3 months (typically resolve by 3 months)
Behavioral changes, memory, concentration issues are normal/expected
What to report ASAP or bring in right away:
- Vomiting
- Suddenly report blurred vision, or any LOC
(Generally later signs of ICP)
Worry about repeated concussion, repeated injuries
A lot of sudden death in sports is related to multiple injuries
Rule of thumb
3 head injuries during contact sports and you’re done – no more contact sports
Contusion and laceration
Terms used to describe visible bruising and tearing of cerebral tissue
Coup—bruising at the point of impact
Contrecoup—bruising at a site far removed from the point of impact (brain hits the back of the skull)
KNOW with any head injury
Assess ABCs first
THEN stabilize head and neck
Reye Syndrome (RS)
- A disorder defined as metabolic encephalopathy associated with other characteristic organ involvement
- Characterized by fever, profoundly impaired consciousness, and disordered hepatic function
- Etiology is not well understood
- Most cases follow a common viral illness (usually influenza or varicella)
- Potential association between aspirin therapy for fever and development of RS
** If you think a child has varicella or influenza, educate parents do NOT give any aspirin or aspirin-containing products (a lot of cold preps can also contain aspirin)
Diagnostic evaluation
Definitive diagnosis by liver biopsy
Majority of children recover rapidly – if intervention is done early
1/3 of patients can die or have long-term neuro deficits
