Peds Neuro Flashcards
Components of a Neurologic Assessment
- History
- LOC
- Cranial Nerves
- Fontanels & Sutures
- Pupils
- Vital Signs
- Posture
- Muscle strength & tone
- movement & gait
- pain
- meningeal irritation
- s/sx of increased intracranial pressure
Level of Consciousness
- Most important indicator of neurologic dysfunction and increasing intracranial pressure
- Alertness
- Cognition
Fontanelles & Sutures
- Bulging fontanelle
- Sunken fontanelle
Decorticate
Hands curled up together over heart
Decerebrate
Hands by person’s side, curled
Muscle strength-0
no contraction
Muscle strength- 1
Slight contraction, no movement
Muscle strength-2
Full range of motion w/o gravity
Muscle strength-3
Full range of motion with gravity
Muscle strength-4
Full range of motion, some resistance
Muscle strength-5
Full range of motion, full resistance
Signs of meningeal irritation
- Kernig’s Sign
- Brudzinksi sign
Intracranial dynamics
- Autoregulation
- Compliance
- Cerebral blood flow
- Cerebral metabolic rate
- Cerebral perfusion pressure
Early Signs of Increased ICP
- Headache
- Emesis
- Change in LOC
- Decrease in GCS
- Irritability
- Sunsetting
- Decreased eye contact
- Pupil dysfunction
- Cranial nerve dysfunction
- Seizures
Late Signs of Increased ICP
- Bulging fontanels
- Decreased spontaneous movements
- Posturing
- Papilloedema
- Pupil dilation with decreased or no response to light
- Increased blood pressure
- Irregular respirations
- Cushing’s triad (ominous sign)
Hydrocephalus
- Not a disease
- Group of conditions from impaired circulation, absorption, or overproductions of cerebral spinal fluid by the choroid plexus
Types of Hydrocephalus
- Obstructive (non-communicating)
- Non obstructive (communicating)
Causes of hydrocephalus
- Congenital (chiari malformation)
- Acquired (post-meningitis, TBI)
Causes of hydrocephalus-clinical manifestations
- Bulging anterior fontanel, dilated cranial sutures
- Dilated scalp veins
- Irritability, decline in LOC
- Sunset sign & Bossing of skull
- Child post closure of sutures (morning headaches w/ N&V, personality changes, ataxia & visual problems)
hydrocephalus treatment
- Surgical removal of obstruction or create new flow-path for CSF
- VP shunt
Neural Tube Defects-Etiology
- Unknown
- Folic acid deficiency
- Drugs (anticonvulsant, acne)
- Genetic determinants
- Malnutrition
Myelomeningocele
- Neural tube fails to close & spine has a bony defect that allows protrusion of the meninges, spinal cord, & nerve roots through the defect.
- Can occur along any point of the spinal column.
- Lumbar & Lumbosacral area are the most common.
Neural tube defects- pre-op care
- Child placed in prone position
- Cover sac w/ sterile saline dressing
- Maintain position with towel rolls
- Feed with head to side
- Parent to touch & cuddle infant-need for tactile stimulation.
Neural tube defects- post-op care
- Infection monitoring and safety
- Monitoring VS, tissue perfusion & edema
- Assess for ICP & possible development of hydrocephalus
- Monitor bowel & bladder function
- Emotional support to parents
- Infant placed prone or side-lying
- Pain control
Possible persistent deficits
- Sensory deficit below level of the defect
- Bowel & bladder dysfunction
- Paralysis below level of defect
Craniosynostosis
- Defined as premature closure of the cranial sutures
- Occurs during first 18-24 months of life
- Cause is unknown, perhaps genetic component/underlying disruption of cranial sutures.
- Frontal is the most common form.
- Occipital plagiocephaly results from position during infancy
Craniosynostosis- treatment
- Surgical intervention of sutures fused or severe abnormality
- helmet used for infants under 12 months if sutures not fused.
TBI- Mild
Unconscious <15 min; GCS 13-15
TBI- Mod
Unconscious >15 min; GCS 9-12
TBI- Severe
Unconscious >6 hr; GCS 3-8
Intracranial pressure management
- Proper patient positioning
- Normocarbia
- CSF drainage
- Euvolemic osmolar therapy
- Sedation and analgesia
- Optimal cardiorespiratory status
- Normothermia
- Seizure prophylaxis
Other traumatic injury
- Bleeding
- Fractures
- Spinal cord injury
CNS infections- diffuse
Meningitis- primary involvement of meninges
CNS infections- focal
Encephalitis- brain parenchymal involvement
Bacterial meningitis
- Most potentially serious infections occurring in infants & older children
- High rate of complications and risk of long-term morbidity.
- Newborns & infants at greater risk, because of immature immune system & frequency of conditions leading to meningitis (otitis media, sinusitis, pneumonia)
Bacterial meningitis signs and symptoms
-Headache
-N & V
-Restlessness or Irritability
-Altered LOC
-Fever
-Nuchal rigidity, + Kernig’s and
+ Brudzinski signs
-Photophobia
-Seizures
-Onset is usually sudden over 1-2 days
B. Meningitis complications
- Cerebral edema- leading to anoxia, vascular stasis, vasodilation
- DIC
- Shock
- Elevated ICP
- Brain Death
B. Meningitis diagnosis
- Lumbar puncture
- Evaluate CSF for WBC, protein, glucose, cell count, differential, gram stain & culture
B. Meningitis treatment
- IV antibiotics (7-21 days)
- Corticosteroids
- Restriction of fluids to 2/3rd maintenance in the case of ICP or SIADH
Cerebral Palsy
A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fetal or infant brain. The motor disorder of cerebral palsy are often accompanied by disturbances of sensation, perception, cognition, communication, and behavior, by epilepsy, and by secondary musculoskeletal problems.
Spastic CP
- Hypertonicity & most common type
- Diplegia: affects primarily the legs
- Quadriplegia: all limbs
- Hemiplegia- arm and leg on one side
Dyskinetic CP
- All limbs and trunk
- Choreform
- Dystonic
Ataxia CP
Abnormal decrease in muscle tone
Mixed CP
Presence of more than one subtype
CP- clinical manifestations
- Motor impairment
- Sensory impairment
- Cognitive impairment
- Visual impairment
- Hearing impairment
- Oromotor function – speech, feeding
CP-treatment
-Multisystem – medical, surgical, neurophysiology
-Multidimensional - PT, OT, Speech, Nutrition
-Focus is on the child’s
physical and developmental needs, and maximizing potential
Autism
-Autism is the most common type of the autistic spectrum disorders
Autism prevalence
- More common in males
- Males with milder form
- Peak age 6-11 years with early symptoms appearing 18-24 months
Seizure Disorders
- Time-limited change in motor activity and/or behavior that results from abnormal electrical discharge from neurons in the cerebral cortex.
- Site of origination- in the brain & extent of abnormal neural activity determines the type and manifestation of the seizure.
- Underlying CNS dysfunction.
Epilepsy
A “syndrome” characterized by recurrent, unprovoked seizures.
Seizure disorders- incidence
- Between 2-10% of children experience a seizure during childhood.
- Most commonly seen during infancy
Seizure disorders- etiology
-Inside or outside brain
Seizure disorders- originating inside the brain
- Cysts or tumors
- Vascular maliformations
- Genetic predisposition
- Neuromuscular degenerative disorders
- Head trauma
Seizure disorders- originating outside the brain
- Fever
- Infection
Seizure disorders- classifications
- Febrile
- Partial (simple, complex)
- Generalized (absence, tonic-clonic, myoclonic, infantile spasms)
- Psychogenic
Febrile seizures
- Most common seizure disorder during childhood
- Age dependent- seen between 3 months-5 years of age
- Peaks between 17-24 months
- Seen in about 4% of all young children
- Rapid rise of core body temperature > 39 celsius.
- 50% of children with febrile seizures have recurrent seizures with later episodes of fever
Febrile seizures- clinical manifestations
Tonic-clonic movements for about 15 minutes followed by a postictal period.
Carbamazepine (Tegretol)
-May decrease activity of conraceptives, causes sedation, dizziness, aplastic anemia, urinary retention. Monitor for hepatic toxicity or hematologic disorders
Phenytoin (Dilantin)
Gingival hyperplasia, hirsutism, blood dyscrasia; liver damage
Gabopentin (Neurotin)
Do not withdraw med aburptly
Lorazepam (Ativan)
Significant resp. depression or hypotension.
