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Pediatrics
MANAGEMENT OF ILLNESSNEUROLOGICAL
CCRN EXAM FOCUS: 14%
 Acute
SCI
 Brain death
 Congenital
abnormalities
 Encephalopathy
 Head Trauma
 Hydrocephalus
 Intracranial
Hemorrhage
 Neuromuscular
disorders
 Seizure disorders
 Space-occupying
lesions
 Spinal fusion
 Stroke
 Infectious disease
QUESTION
Baby Joey who was
admitted for bacterial
meningitis has a hearing
test scheduled prior to
discharge. The parents
are concerned and ask
why is a hearing test
necessary? Your best
response to them would
be…
QUESTION
.
CONT
A. It necessary to make sure your child is
developing appropriately
B. The test will identify issues such as attention
deficit disorder
C. Its necessary to make sure the antibiotic and
steroid therapy received in the hospital didn’t
affect baby Joeys hearing
D. Some children with bacterial meningitis suffer
neurologic damage especially to the nerve
responsible for hearing
THE NEURO EXAM
How
do you assess
someone’s
Neurological
Status?
What
are you
looking for?
LEVEL OF CONSCIOUSNESS (LOC)
 Assessment
of LOC
remains the earliest
indicator of
improvement or
deterioration in
neurological status.
 GCS
PEDIATRIC GLASGOW COMA SCALE
 Three
part
assessment:
 Eyes
 Verbal
response
 Motor
response
GLASGOW COMA SCALE
1
2
3
4
5
6
Eyes
Does not
Opens eyes in
response to
painful stimuli
Opens eyes in
response to
voice
Opens eyes
spontaneously
N/A
N/A
Verbal
Makes no
sounds
Incomprehensible
Utters
inappropriate
Confused,
disoriented
Oriented,
converses
normally
N/A
Flexion /
Withdrawal to
painful stimuli
Localizes
painful
stimuli
Obeys
Command
s
open eyes
sounds
words
Motor
Makes no
Extension to
painful
movements
stimuli
Abnormal
flexion to
painful
stimuli
VARIATIONS IN PUPIL SIZE WITH ALTERED
STATES OF CONSCIOUSNESS
NEUROLOGY
TERMS
Full Consciousness
 Awake,
alert and
oriented to time,
place and person;
comprehends the
spoken and written
word and is able to
express ideas
verbally or in
writing
Demonstrates
reliable and
responsible
behavior
CONFUSION

Disoriented in time, place, or person; initially
becomes disoriented to time, then to place, and finally
to person; shortened attention span; memory difficulty
is common; becomes bewildered easily; has difficulty
following commands; exhibits alterations in perception
of stimuli; may have hallucination; may be agitated,
restless, irritable, and increasingly confused at night
High risk for falls and injury
Requires frequent observation
and supervision
High risk for falls and injury
LETHARGY
Oriented to time, place,
and person; very slow
and sluggish in
speech, mental
process, and motor
activities; responds
appropriately to
painful stimuli
High risk for falls
and injury
Needs frequent
observation and
supervision
OBTUNDATION
Arousable with
stimulation; responds
verbally with a word or two;
can follow simple
commands appropriately
when stimulated; otherwise
appears very drowsy;
responds appropriately to
painful stimuli
High risk for
injury
STUPOR
 Lies
quietly with minimal
spontaneous movement;
generally unresponsive
except to vigorous and
repeated stimuli;
incomprehensible sounds
and or eye opening may be
noted responds
appropriately to painful
stimuli
High risk for
injury
Unable to
assume any
responsibility
for self; needs
complete care
COMA
Appears
to be in
a sleeplike state
with eyes
closed; does not
respond
appropriately to
bodily or
environmental
stimuli
High risk for injury
and aspiration
Needs standard of
care appropriate
for comatose,
completely
dependent patient
THE BRAIN
The
brain is
complex! Every
lobe in the
cerebrum is
responsible for
another
function.
REGIONS OF THE BRAIN/CEREBRUM
Processing of sensory
input, sensory
discrimination. Inability
to discriminate
between sensory
stimuli. Inability to
locate and recognize
parts of the body
(Neglect). Severe Injury:
Inability to recognize
self.
CEREBELLUM
The
Cerebellum is
located in the
posterior
fossa of the
cranium
THE BRAIN STEM
Controls
vital
functions
 Divided
into 3
segments
 Midbrain
 Pons
 Medulla
INSIDE THE SKULL
80%
Brain
10%
CSF
10%
Blood
NEURODIAGNOSTIC MONITORING
X-ray- skull fractures, widened sutures, some tumors,
calcification, bone erosion
 CT Scan- acute neurologic dysfunction, lesions,
cortical structures of the skull and spine
 MRI- small infarcts, infections, inflammatory areas,
demyelinating plaques
 Angiogram- not as commonly used- used for
confirmation of lesions, identification of vascular
occlusions, stenosis, ulceration, & dissection of large
arteries
 Radioisotope scan- also limited used- good with
identifying dense lesions (blood clots, subdural
hematoma, infection, inflammation)

NEURO PHYSIOLOGIC MONITORING- ICP
Catheter is placed within cranium- assessing to
prevent herniation and preservation of cerebral
perfusion
 Various types of transducers:

Fluid filled systems
 Fiber-optic catheters




Catheter-tip strain-gauge
External fiber-optic
Anatomic locations





Intraventricular
Subarachnoid- bolts
Subdural catheters
Epidural catheters
Intraparenchymal fiber-optic transducer
OTHER NEURO PHYSIOLOGIC MONITORING

TCD- transcranial Doppler ultrasound
Velocity signals from Doppler can help with measuring
blood flow changes
 Useful for dx of vasospasm, vessel occlusion, cerebral
emboli, CO2 and BP vasoreactivity, and some ICP changes


Xenon CT
Uses xenon to measure brain tissue buildup- rate up
uptake is proportional to blood flow
 Used to dx stroke, cerebral HTN, confirmatory test for
brain death


EEG
Records spontaneous electrical activity across surface of
brain
 Used for dx of epilepsy, dementia, diffuse
encephalopathies, brain lesions, some infxns, brain death

OTHER NEURO PHYSIOLOGIC MONITORING

Evoked potential studies:
Measure electrical activity produced by a specific neural
sensory pathway
 Measured as an ER “evoked response”
 Slower than EEG
 Used to identify dysfunction in specific pathways such as:

VER- visual (blindness, eyesight problems in peds & multiple
sclerosis, Parkinson disease, occipital lobe tumors, CVA)
 BAER- hearing (auditory disorders, posterior fossa tumors, cva of
the brainstem or temporal lobe cortex, auditory nerve damage,
acoustic nerve neuroma, demyelinating diseases
 SER- sensory stimulus applied to a certain area of the body
(detecting SCI and can monitor SCI function during surgery

ASSESSING METABOLIC ALTERATIONS

Jugular venous oxygen saturations (SjO2)
Measures the balance between cerebral O2 delivery
and cerebral oxygen consumption
 Typically a 16-20 gauge catheter used to thread a 4 fr
fiber-optic catheter (usually the right side)
 Normal values are between 60-75%


Abnormalities that can increase O2 consumption:


Abnormalities that can decrease delivery


Fever or seizures
Increased ICP, hypotension, hypoxia, hypocapnia,
anemia
Mainly used to evaluate and manage cerebral
ischemia
ASSESSING METABOLIC ALTERATIONS CONT.

Brain Tissue Oxygen Monitoring (PbtO2)
Relatively newer technique
 Inserted through bolt into white matter of the brain
 Ranges are between 25-35 mm Hg
 Used to identify patients at risk for cerebral ischemia
and evaluate the effectiveness of interventions that alter
cerebral oxygenation (TBI, SAH, ischemia, or
intraoperative monitoring


Lumbar puncture & CSF analysis:
Assessment of CSF composition
 Key pearls:


Topical and local anesthetic, knees flexed to chest, back must be
close to the edge of the procedure table,
INTRACRANIAL DEVICES

EVD






Temporary catheter placed in the lateral ventricle. It is
then externalized through a secondary incision after being
tunneled under scalp
Needs to be attached to an ICP monitoring catheter, if not,
it will just function as a drain and connected to an
extraventricular drain
Used for CSF drain for acute intracranial HTN, vent.
Shunt malfunction, acute hydrocephalus following
intracranial hemorrhage
MD will order care, flow,
Keep head at 30 degrees to facilitate drainage
Knowing when to clamp and unclamp:
Clamp for to much CSF drainage, transport, vigorous activity
 Unclamp for increased ICP

INTRACRANIAL DEVICES
 Ventricular
Shunt- internal catheter system to
drain the lateral ventricles by bypassing part
of the system. Left side is normally avoided
due to the speech center.
 Tunneled catheter under the skin with a
reservoir (one-way valve) and pumping
device.
 Distal tubing is attached, with the end point
in some other area of the body (usually
abdomen)
 Mainly used for acute and chronic
hydrocephalus
KEY CARE COMPONENTS

Zeroing & Calibrating
Fiber-optic transducers are calibrated before insertion
but can also be at the bedside monitor as well
 Fluid filled transducers need to be level at the formen
on Monro (outer canthus of eye, tragus of the ear). This
needs to be checked with every position change


Insertion site care





Aseptic technique
Dry, dressing
Frequent assessment
Minimize number of stopcock connections
Waveform Analysis
ICP Pressure monitoring
SET-UP VIDEO

EVD

https://youtu.be/oeLCiecrMuE
HYDROCEPHALUS
HYDROCEPHALUS
Hydrocephalus
is
a syndrome, or
sign, resulting
from disturbances
in the dynamics of
cerebrospinal fluid
(CSF)
CAUSES OF HYDROCEPHALUS
 Impaired
absorption of CSF
fluid within the
subarachnoid
space
(communication
hydrocephalus)
 Obstruction
of the
flow of CSF through
the ventricular
system (non
communicating
hydrocephalus)
CHANGES WITH HYDROCEPHALUS
• Bulging anterior
fontanel
• Eyes deviated
downward also
known as “Setting”
Sun sign
• Vomiting, irritability,
sleepy
HEAD CIRCUMFERENCE
 Enlarged
 Maintain
measurements at
regular intervals
 Consistent
measuring
indicators
 Anterior
and Posterior
Fontanel's
HYDROCEPHALUS TREATMENT
VP Shunt
 Catheter is fed through
skull into ventricle to
relieve excess fluid and
pressure from CSF
buildup
 Second catheter is fed
through the body and
into the abdomen. This
serves as the receptacle
for the excess fluid
QUESTION
The parents of an
infant who has
just had a VP
shunt inserted for
hydrocephalus are
concerned about
the infant's
prognosis and
ongoing care.
Nurse Abigail
should explain
that:
A. The prognosis is excellent
and the shunt is permanent.
B. The shunt will need to be
revised as the child gets older.
C. During the first year of life,
any brain damage that has
occurred is reversible.
D. Hydrocephalus is usually
self-limiting by 2 years of age
and the shunt will then be
removed
TUMORS OF THE BRAIN
BRAIN TUMORS



Primarily brain tumors are the most
common form of cancer in children ages 510 years old
Symptoms are generally related to
location and resulting increased ICP
Classification depends on location,
degrees of malignancy, and histology
features
Astrocytomas
• Glial cell tumors that are derived
from connective tissue cells called
astrocytes.
• These cells can be found anywhere
in the brain or spinal cord.
Ependymomas
• Also glial cell tumors. They usually
develop in the lining of the ventricles
or in the spinal cord.
• The most common place they are
found in children is near the
cerebellum. The tumor often blocks
the flow of the CSF
Brain Stem
Gliomas
• Tumors found in the brain stem.
Most brain stem tumors cannot
be surgically removed because
of the remote location and
delicate and complex function
this area controls
TUMORS: CEREBELLAR ASTROCYTOMAS
 Account
for 12% of
all brain tumors in
children
 Usually
are located
in the posterior
fossa
TUMORS: Supratentorial Astrocytomas
 Most
common
supratentorial
tumor
 Graded
I-IV, the
lower the grade
the better
prognosis
TUMORS: MEDULLABLASTOMA
 Most
common tumor of
the posterior fossa
 Malignant
tumors that
enlarge quickly, have
symptoms detected
within 3 months from
onset and are found
almost exclusively in
children
TUMORS: EPENDYMOMAS
 Located
in the fourth
ventricle in young
children and the lateral
ventricles in older
children and adolescents
 Either
supra (above the
tentorium) or
infratentorial (below the
tentorium)
TUMORS: THERAPEUTIC MANAGEMENT
Chemotherapy
Radiation
Surgery
**Think about
nursing
management**
SEIZURES
SEIZURES
 Seizures
are the most
common neurologic
disorder seen in children
 Febrile
seizures are the
most common form of
childhood seizures with
the peak incidence at
18months of age.
 How
many
of you
have cared
for a
child who
is actively
seizing???
SEIZURE CATEGORIES
Partial
 Inclusive
of..simple partial
seizures
(consciousness not
impaired),
complex partial
seizures
(impairment of
consciousness)
Generalize
 Include
absence
seizures, atypical
absence seizures,
myoclonic
seizures, clonic
seizures, tonic
seizures, and
tonic-clonic
seizures
SEIZURE DRUGS
o
Benzodiazepines act
rapidly and are
used as a first line
agent
o
Lorazepam (ativan)
Midazolam
(versed)
o Diazepam
(valium)
o
 Common
side effects
of benzodiazepines
include:





Drooling
Drowsiness or
sedation.
Loss of muscle
coordination.
Behavior changes
(nervousness,
confusion,
aggression).
Loss of appetite
SEIZURE DRUGS
 Dilantin
(phenytoin): Side Effects
an anti-epileptic drug, Include:
also called an
Gum
anticonvulsant. It
hypertrophy
works by slowing down
Hirsuitism
impulses in the brain
that cause seizures.
(body hair)
QUESTION
Seizure activity without
impaired consciousness
that is usually confined
to a restricted area of
the brain and may
include twitching of an
arm/leg is a:
a.Tonic-Clonic
b.Generalized
absence
c. Complex partial
d.Simple partial
ENCEPHALOPATHY &
MENINGITIS
Encephalopathy
 Defined
as an acute
inflammation of the
brain and meninges
 Signs
and symptoms
are typical of
increased ICP
 Treatment
is aimed a
supportive care with
a goal of decreasing
ICP
Meningitis
 Inflammation
of
the meninges
that is
identified by an
abnormal rise in
white blood cells
in the CSF. It
can be Bacterial
or viral
CLINICAL MANIFESTATIONS OF MENINGITIS
Fever
Nuchal
Photophobia
Kerning's
Headache
Brudzinski’s
sign
rigidity
sign
BRUDZINSKI'S SIGN
 To
test for Brudzinski's
sign, have the child lie in
a supine position.
 Flex
the child's head
forward. If the knees or
hips flex automatically,
this sign is positive. If
they do not, it is negative.
A
positive Brudzinski's
sign is a common finding
in meningitis.
BACTERIAL MENINGITIS
High
Protein
• (Normal 1030 mg/dl)
Low
Glucose
•(Normal 40
to 80 mg/dl)
Elevated
WBC’S
•Normal
(4.5-10.5)
BACTERIAL MENINGITIS
Streptococcus
pneumonia
Haemophilus
influenza
Group B
streptococcus
Neisseria
meningitis
Escherichia coli
VIRAL MENINGITIS
 Less
common than bacterial, occurs
sporadically
 Usually
caused by Enteroviruses
 Spread
from person to person usually
with mouth and nose as ports of entry
 Typically
last 10-14 days with only
supportive treatment
VIRAL MENINGITIS
Elevated WBC’S
Normal Glucose
Negative Gram
Stain
Normal To Slightly
Increased Protein
TRAUMATIC BRAIN INJURY (TBI)
TRAUMATIC BRAIN INJURY
A
traumatic brain
injury, or TBI, is an
insult to the brain
caused by an
external force and
not of a degenerative
or congenital nature
TRAUMATIC BRAIN INJURY
Primary
Secondary
skull fx’s
 Concussiontransient loss of
awareness

Cerebral lacerations
 Cerebral contusions
 Extradural
hematomas
 Diffuse generalized
cerebral swelling

Basilar skull fx signs
Raccoon eye
Battle’s sign
Blood and CSF leak
TBI
SPINAL CORD INJURY
SPINAL CORD INJURY

The complete loss of motor and sensory function d/t
interruption of nerve pathways below the level of
the injury


Quad or para
Incomplete loss can occur- some loss and sparing of
function





Posterior cord syndrome- loss of proprioception
Anterior cord syndrome- loss of motor function below
level of injury. Can feel vibrations and have
proprioception
Central cord syndrome- deficits vary depending on
location, bowel and bladder dysfunction
Partial spinal cord syndrome- injury to 1 side of the
spinal cord with loss of voluntary control, deficits on
opposite side as well
Conus Medullaris- injury to sacral cord and lumbar
nerve roots, areflexia of bowel/bladder, and lower limb
SCI
Sequelae
o ICF and ECF changes- increases in amino
acid, free 02 radicals formation, calcium
homeostasis, platelet-activating factor
leading to edema cell membrane damage,
ischemia
o Death from high cervical injuries
o Spinal shock- complete loss of reflex function
(7-20 days) can occur within 1 hr. of initial
injury
o Autonomic dysreflexia
o Temperature regulation instability
SCI
Management:
o Immobilization of spine
o Spinal cord decompressin
o Fusion (surgical fixation)
o Medication
o
Solu-Medrol
o
Loading dose followed by a maintenance dose cont.
FUSIONS
What are your post-op
concerns?
NEAR DROWNING

Drowning is defined as
submersion resulting
in asphyxia and death
within 24 hours,
whereas near drowning
is defined as
submersion resulting
in the need for
hospitalization but not
resulting in death
within 24 hours.

Near drowning is one
of the leading causes
of death in children 14 years of age in the
U.S
WHAT'S WRONG WITH THIS PICTURE?
INTRACRANIAL
HEMORRHAGE
AV MALFORMATION
Abnormal connection between arteries and veins
without a capillary bed in between
 Most common cause of spontaneous, intracranial
hemorrhage
 Present at birth however symptoms may not
manifest until later in life

Seizures
 Headaches
 CHF- mainly in infants d/t the increase in cardiac
output needed to support the blood flow of the AVM

So how do we dx?
 Treatment depends on the size

Surgical- excision,
 Gamma knife radiosurgery- laser therapy
 Embolization

CASE STUDY:
Mary, a 9-year-old, fell 20 feet from a tree house.
Upon impact she lost consciousness for approx. 2
minutes. When the paramedics arrived she was
conscious with a GCS of 14. she was breathing
spontaneously at 26 bpm, HR was 110, bp was
110/72. the c-spine was immobilized and she was
transferred to the ED.
while in the ED she had periods of irritability
alternating with unresponsiveness and apnea. Her
GCS decreased to 8. she was intubated and 2 piv’s
were started. A 20ml/kg bolus of NSS was given.
She was transferred to CT which revealed a
hyperdense area and midline shift
QUESTION 1

The CT scan report best
describes which of the
following?
a.
b.
c.
d.
Subdural hematoma
Epidural hematoma
Diffuse cerebral
swelling
Intracranial
hematoma
QUESTION 2

What is the treatment
of choice?
a.
b.
c.
d.
Return the patient to
the ED and continue to
assess neuro status
Transfer to the PICU
for more monitoring
Remain in the radiology
dept. for CT scans of the
chest and abdomen
Transfer pt. to the OR
for evacuation of clot
QUESTION 3
Several hours later, the
patient is in PICU. She
is intubated and
ventilated. She has icp
monitoring as follows:
Arterial pressure: 110/65
mm Hg
MAP 80 mm Hg
ICP 18 mm Hg
PbtO2 24 mm Hg
Heart rate 122

What is her CPP
(cerebral perfusion
pressure?)
A. 56 mm Hg
B. 30 mm Hg
C. 62 mm Hg
D. 130 mm Hg

CPP= MAP-ICP
80-18= 62
QUESTION 4

Which of the following
sets of parameters has
the worst prognosis?
a.
b.
c.
d.
ICP 15, CPP 50, PbtO2 30
ICP 25, CPP 65, PbtO2 22
ICP 10, CPP 80, PbtO2 40
ICP 12, CPP 40, PbtO2 15
D= look at the CPP and the PbtO2- it
represents ischemia. A PbtO2 less than
15 mm Hg correlates with a high
mortality
QUESTION 5

On day 2, Mary’s CPP
is 40 mm Hg and ICP
is 25 mm Hg. Her
PbtO2 is 15 mm Hg.
Which of the following
are first line
interventions to
improve her
condition?
a.
b.
c.
d.
Increase MAP with
fluids and vasopressors
Hyperventilate to
achieve a PaCO2 of 30
mm Hg
Start a pentobarbital
drip
Administer phenytoin
QUESTION 6
Despite fluids,
vasopressors, sedation,
paralysis, and mannitol.
Mary’s ICP remains less
than 25 mm Hg, CPP is
less than 50mm Hg, and
Pbto2 is less than 20. a
decision is made to start
a pentobarbital infusion
Which of the following
infusions is commonly used
with a pentobarbital
infusion?

a.
b.
c.
d.
Dopamine
Vecuronium
Mannitol
Morphine