-
When does school age occur?
- 6-12.
- Shedding of first tooth-final tooth
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When does Puberty occurf?
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What is Cognitive Development (Piaget)?
- Concrete operations
- Make judgements on what they reason
- Conservation: Changing shape doesn't alter mass
- Classification: Group objects by logical order
- Ability to read & tell time
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Who do kids socialize with?
- Peer group
- Club
- Best friends (same-sex peers)
-
What is bullying?
- Physical or psychological abuse
- Bully: defiant, antisocial
- Victim: characteristics differ from norm, can develop LT depression & low self esteem
-
What is Play for School Aged Kids?
- Rules & Rituals: Conformity
- Team Play: Competition
- Quiet Games & Activities: Collections, Board/card/computer games, Reading
- Ego Mastery: Can feel powerful & skillful as their imaginations allow. Need large muscle play
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What is Dental health?
- 1st permanent teeth erupt: 6 yr
- Dental Caries: #1 oral problem in kids/teens
- Maclocclusion problems: Irregular eruption of permanent teeth may impair function. Upper and lower teeth don't approximate
- Dental Injury: require prompt DDS eval
-
What is the most common cause of severe injury or death?
- MVA
- Rear car seat is safest <13 yr
-
-
When is Adolescence?
11-20
-
What are primary/secondary sex characteristics?
- Primary: External & internal organs that carry out reproductive functions
- Ovaries, uterus, breasts, penis
- Secondary: Changes throughout the body; result from hormones
- Voice alterations, facial & pubertal hair, fat deposits
-
When does physical growth occur?
Final 20%-25% of height during puberty
Most of the growth during a 24-36 month period growth spurt
-
What is social development?
- Acceptance by peers
- A few close friends
- Secure love of a supportive family
- Seek mutual affection & equality with parents
-
What are adolescent injuries?
Propensity for risk-taking behavior & feeling of indestructibility
- 40% of all teen deaths in US are from MVA
- seatbelts, firearms, sport injuries
-
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What classifies cognitive impairment/mental retardation? Educable/Trainable?
IQ 75 or below. Delay in gross, fine motor, speech
Educable mentally retarted: mildly impaired 85%
Trainable mentally retarted: moderately impaired 10%
-
What is Down Syndrome (Trisomy 21)?
Extra chromosome 21
↑ risk in women > 35 yoa
- Majority of infants: born to women < 35 yoa
- Translocation:
(3-4%): Hereditary; not associated with advanced parental age - Mosaicism:
(1-2%): Cells with both normal & abnormal chromosomes
> 80% survive to age 55 & beyond
-
What are problems associated with down syndrome?
Congenital heart malformations
- ↑ respiratory tract infections
- –Hypotonicity of chest & abdominal muscles
- –Impaired immune system
Thyroid dysfunction (hypothyroidism)
↑ incidence of leukemia
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What is Fragile X Syndrome?
Abnormal gene on the lower end of the long arm of the X chromosome
- Adult men
- –Long face with prominent jaw
- –Large, protruding ears
- –Large testes
Children & carrier females: varied manifestations
Behavioral signs: Cognitive impairment, violent temper outbursts, attention deficit, speech delay, hyperactivity
Normal life span
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What is conductive or middle-ear hearing loss?
- Most common
- Interference with loudness of sound
- From recurrent serous otitis media
- If permanent: hearing aid to amplify sound
- Absence of well-formed syllables by 11 months of age should result in immediate referral
-
What is sensorineural hearing loss?
- Damage to the inner ear structures or auditory nerve.
- Distortion of sound & problems in discrimination
- From congenital defects or acquired conditions: kernicterus, infection, ototoxic drugs, or excessive noise
- Hearing aids do not work as well
- Use cochlear implant: bypasses hair cells to directly stimulate surviving auditory nerve fibers to send signals to the brain; usually by 18 months of age
- Usually has difficulty in articulation
-
What is mixed?
- Interference with transmission of sound in the middle ear & along neural pathways
- From recurrent otitis media
-
What is Central auditory imperception?
- No defects in conductive or sensorineural structures
- Includes problems expressing the message into meaningful communication
-
What are types of visual impairment?
- Myopia
- Hyperopia
- Astigmatism
-
What is myopia?
Light rays fall in front of the retina
Nearsighted (see near objects, but not far)
Corrective lenses or surgery
-
What is hyperopia?
Light rays fall beyond the retina
Farsightedness (see objects at a distance)
Corrective lenses or surgery
-
What is Astigmatism?
Unequal curves in refractive apparatus
Corrective lenses or surgery
-
What is Amblyopia?
Lazy eye
Reduced visual acuity in one eye
-
What is Strabismus?
Cross eye
Eye patch or sx
-
What are cataracts?
Opacity of the lens
Sx
-
What is glaucoma?
Increased intraocular pressure
-
What is a common cause of blindness in children?
Trauma: foreign objects, penetrating injuries, chemical burns, infections
-
What is Retinoblastoma?
Most common congenital malignant intraocular tumor of childhood
Mutated gene unable to produce natural signals to stop growth of retinal cells
- Majority: nonhereditary & unilateral
- Cat’s eye reflex
: whitish “glow” in the pupil - Tx: (based on stage of tumor):
- -Surgical radioactive implant, laser photocoagulation, cryotherapy, thermotherapy &/or chemo
- -Enucleation: removal of eye
90% survival
-
What is Autism?
- Complex developmental disorder of brain function with a broad range & severity of intellectual & behavioral deficits
- Manifests between 24-48 months
- 4xs more common in boys
- NOT related to: socioeconomic level, race or parenting style
- Genetic disorder of prenatal & postnatal brain development (2006)
- Immune & environmental factors (e.g., virus) may interact with genetic susceptibility
- Possible autosomal recessive inheritance (60%-96% monozygotic twins)
- No specific gene has been identified
- Does not appear to be caused by MMR vaccine or thimerosal-containing vaccines
-
What are clinical manifestations/treatment of autisim?
- Speech & language delays are common
- Refer: any child who does not babble or gesture by 1 yoa, single words by 16 months, 2-word phrases by 24 months
- Tx:
- Early intervention programs
- Highly structured & intensive behavior modification programs
-
What is ADHD?
- Developmentally inappropriate degrees of inattention, impulsiveness & hyperactivity:
- Must be present before 7 yrs
- Symptoms must be present in two settings
- Affect written & adaptive skills, social status & self-esteem
- Learning Disability:
- Significant difficulties in acquisition & use of listening, speaking, reading, writing, reasoning or mathematic skills
-
What is Therapeutic mgmt for ADHD?
Behavioral: focus on preventing undesired behavior. Reward system. Age appropriate consequences.
Environmental: consistency between families and teachers (same goals). Structured. ↓ distractions
- Pharmacologic:
- Psychostimulants:
- –Ritalin & Dexedrine
- –↑ dopamine & norepinephrine levels that stimulate inhibitory system of the CNS
- –Side effects: insomnia, anorexia, ↑ BP
- Tricyclic antidepressants:
- –Imipramine, desipramine & nortriptyline
- –Block norepinephrine & serotonin at the nerve endings & ↑ the action in nerve cells
Clonidine: used with sleep disturbances
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How does Immobilization affect musculoskeletal system?
- Muscle disuse—tissue breakdown & atrophy
- –↓ strength & endurance
- Joint contracture: altered collagen arrangement
- –Denser tissue—doesn’t glide easily
- –Shortens muscle, tendons & ligaments—↓ joint movement—contracture—↓ function
- Daily stress on bone from weight bearing maintains balance between bone formation & resorption
- –↑ calcium leaves bone—osteopenia—fx?
-
How does Immobilization affect other systems?
- •Metabolism:
- –↓ rate, ↑ calcium, ↓ stress hormone production
- •Respiratory:
- –↓ O2 need, ↓ chest expansion, ↓ respiratory muscle strength
- •↑ URI
- •Cardiovascular:
- –Altered distribution of blood volume, dependent edema
- •Orthostatic hypotension, pulmonary emboli, tissue breakdown
- •GI:
- –Distension from poor abdominal muscle tone
- •Constipation, anorexia
- •Urinary:
- –Impaired peristalsis
- •Urinary retention—infection & renal calculi
- •Skin:
- –Tissue injury & ↓ healing
-
What are the different types of Soft-Tissue Injury?
- •Contusions:
- –Damage to soft tissue, subcutaneous structures & muscle
- –Ecchymosis (cold tx: 24-48 hrs)
- •Dislocation:
- –Ligaments hold bones in place
- –Stress on ligament displaces the normal position of the opposing bone ends or bone end to its socket
- •Sprains:
- –Ligament is torn or stretched with damage to other tissues; “feeling loose”
- •Strains:
- –Microscopic tear to musculotendinous unit; pain to touch & swollen; more rapid the strain = more severe
-
What is the process of bone healing & remodeling?
- •Hematoma: “procallus;” 24-48 hr
- •Cellular proliferation: within 2 wks
- –Hematoma changes to granulation tissue & callus forms a soft collar around fx site to connect bone fragments
- •Callus: “bony callus;” 3-4 wks
- •Ossification: mature bone; 3-10 wks
- •Remodeling: resorption of excess; 9 mo.
-
What are goals of therapy?
- Reduction
- Immobilization
- Restore function
- Prevent further injury
-
What are types of casts?
- Synthetic: light, quick dry, water resistant, early weight bearing, rough exterior, $, different colors, difficult to write on
- Plaster: molds closely, long dry time, smooth exterior, inexpensive
-
What do you check with someone who has a plaster cast?
Neurovascular checks a priority
-
What do hot spots in a syntetic material cast mean?
“Hot” spots after dry may mean infection
-
What is traction?
- •3 components:
- –Traction (wt to distal bone fragment)
- –Counter traction (body wt)
- –Friction (bed contact)
- •Purposes:
- –↓ muscle spasm
- –Position distal & proximal ends
- –Immobilize
- •All-or-none law:
- –Stretch muscles—spasm stops—can realign bone!
-
What are types of traction?
- •Manual: applied by the hand distal to fx
- •Skin: applied directly to skin surface & indirectly to skeletal structures
- •Skeletal: applied directly to skeletal structure with pin, etc.
-
What is Illizarov External Fixator?
- •Limb lengthening to occur by manual distraction
- –Separating opposing bone to encourage regeneration of new bone in the space
- •Wires, rings, rods
- •Percutaneous ostomy: create a “false” growth plate
- •Bone growth: 1 cm/mo (max 15 cm)
- •Crutch walking, pin care
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What is Developmental Dysplasia of the Hip (DDH)?
- Abnormal hip development
- 16-25% born breech
- 60% female; caucasian
- Risks:
- Physiologic: mom's hormones
- mechanical: breech, multiple fetus, large
- genetic: family hx
-
What are types of DDH?
- •Dysplasia: mildest; delay in acetabular development
- •Subluxation: majority; partially displaced femur head
- •Dislocation
-
What is treatment for DDH?
ASAP
- •Birth to 6 mo:
- –Harness, spica cast
- •6-18 mos:
- –Traction, reduction, spica cast, bracing
- •Older:
- –Operative reduction & casting
- •Pavlik harness
- •Note: DON’T double/triple diaper!
- –Promotes hip extension
-
What is congenital clubfoot?
•Ankle & foot deformity
•Cause: abnormal embryonic development or in utero positioning
- •Tx:
- –Manipulation
- –Serial casts q 1-2 wks
- –Surgery (failure to achieve normal alignment by 3 mo of age)
Ponseti cast
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What is Metatarsus Adductus (Varus)?
- •Most common congenital foot deformity
- •Cause: abnormal intrauterine position
- •Pigeon-toed gait
- •Tx: manipulation & stretching or casting
-
What is Skeletal limb deficiency?
- •Amelia: absence of entire extremity
- •Meromelia: partial absence of an extremity
- –Phocomelia (seal limbs): interposed deficiency of long bones with relatively good development of hands & feet attached at or near shoulder or hips
- •Amniotic band syndrome: full/partial amputation in utero from constriction of an amniotic band
- •Cause: teratogenic effect of meds in 1st trimester of pregnancy (thalidomide, accutane)
- •Tx: prosthetic devices
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What is Osteogenesis Imperfecta?
- •Hereditary (at least 5 types)
- –Autosomal-dominant (most common)
- –Autosomal-recessive (most severe form)
- •Collagen defect (major component in connective tissue)
- •S&S: fx, osteoporosis, skeletal deformities
- •Tx:
- –Meds: promote ↑ bone density
- –Supportive: rods placed for long bones prn
- –Bone marrow transplant?
- •Nursing care: careful handling to prevent fx!
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What is Coxa Planta (Legg-Calve, Perthes Dz)?
- •Aseptic necrosis of the femoral head
- •3-12 yoa; 4-5x ↑ in boys; ↑ Caucasian
- •Unknown cause
- •Stages:
- –Flattening of upper surface of femoral head
- –Vascular reabsorption of the epiphysis
- –New bone & regeneration of femur head
- •S&S: limp, ache/stiff hip
- •Tx: Traction?, rest, braces, surgery?
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What is Slipped Capital Femoral Epiphysis (SCFE)?
- •Spontaneous displacement of proximal femoral epiphysis in a posterior & inferior direction
- •Before or during accelerated growth
- •↑ males & obese
- •Femoral neck slips—deforms femoral head
- •S&S: hip/thigh/knee pain, limp
- •Tx: Presurgery bed rest & traction followed by surgical pinning
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What is Osteomyelitis?
- •Bone infection: Direct invasion (exogenous) or spread from a preexisting focus (hematogenous)
- •S&S: fever, local pain/swelling/warmth over involved bone, ↓ ROM
- •Cause: Staph (majority)
- •Dx: cx (blood, joint fluid, pus), ↑ WBC & ESR, biopsy, bone scan, x-ray (after 2-3 wks)
- •Tx: IV antibiotics 4-6 wks, no wt bearing @ 1st
-
What are bone & soft tissue tumors?
- •Peak: 15-19 yoa; > males
- •S&S: local pain—limp
- •Osteogenic sarcoma: bone ca; 10-25 yoa; most common in long bones (femur)
- –Tx: surgical resection or amputation, chemo
- –85% survival (non metastatic)
- •Ewing Sarcoma: bone marrow ca; 4-25 yoa
- –Tx: radiotherapy & chemo
- –80% 3 yr survival
- •Rhabdomyosarcoma: soft tissue ca; peak < 5 yoa
- –Tx: radiotherapy & chemo
- –65% survival
-
What is
Juvenile Idiopathic Arthritis (JRA)?
- •Inflammed synovium with joint effusion & erosion
- –Adhesions between joints & ankylosis
- •Peak: 1-3 yoa; > girls
- •Cause: immune & environmental trigger?
- •S&S:
- –Joints (red, warm, swollen, painful, ↓ ROM)
- –Rash? Fever? Lymphadenopathy?
- –Psoriasis? Nail pits?
- –Vision changes? (uveitis—inflammation in the anterior chamber of the eye)
- •Dx: ↑ WBC & ESR?, antibody tests, radiographs, slit lamp exam
- •Tx:
- –Meds: NSAIDs, methotrexate, corticosteroids, immune modulators
- –Supportive: moist heat, PT/OT (maintain muscle strength & joint mobility)
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What is Cerebral Palsy (CP)?
“group of permanent disorders of the development of movement & posture, causing activity limitation, that are attributed to nonprogressive disturbances that occurred in the developing fetal or infant brain” (2006)
- •Most common permanent physical disability of childhood
- •Abnormal muscle tone & coordination
- –Disturbances of sensation, perception, communication, cognition & behavior; seizures
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What are S&S of CP?
- •Delayed gross motor development
- •Abnormal motor performance:
- –Stand or walk on toes; feeding difficulties
- •Alterations in muscle tone: ↑ or ↓
- •Abnormal postures/reflexes
- –Asymmetric or persistent reflexes
- •Moro reflex beyond 4 mo
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How do you diagnose CP?
- •Early assessment
- –Developmental screen & neuro exam
- •Neuroimaging: MRI preferred
- •Metabolic & genetic testing if no brain structural abnormalities found
Dx often cannot be confirmed until 2 yoa: motor tone abnormalities may indicate another neuromuscular illness!
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What is Therapeutic Mgmt for CP?
- •Orthopedic surgery
- –Correct contractures/spastic deformities
- •Control muscle spasms & resulting pain
- –Baclofen (intrathecal pump?) & Valium
- –Botulinum toxin A (Botox): ↓ spasticity in targeted muscles
- •Antiseizure meds
-
What is Spina Bifida (Myelomeningocele)?
- •Defects from failure of neural tube closure
- •↓ : folic acid & prenatal dx tests
- –Educate childbearing adolescent females about the need for folic acid to prevent neural tube birth defects!
-
What are types of Spina Bifida?
- •Spina bifida occulta:
- –Defect not visible externally; lumbosacral
- •Spina bifida cystica:
- –Visible defect with external saclike protrusion
- •Meningocele: encases meninges & spinal fluid
- •Meningomyelocele: contains meninges, spinal fluid & nerves
- •Encephalocele:
- –Herniation of brain & meninges through defect in the skull producing a fluid-filled sac
-
What is Encephalocele?
- •Failure of neural tube closure
- –During 1st 3-5 gestation wks
- –Multifactorial: drugs, radiation, maternal malnutrition/illness, genetics
- •Degree of neuro dysfunction depends on:
- –Vertebral area where the sac protrudes
- –Anatomic level of the defect
- –Amount of nerve tissue involved
- •80%-90%: hydrocephalus
-
What are clinical manifestations?
- •Sac prone to tears
- •Usually: lumbar/lumbosacral
- •If below 2nd lumbar vertebrae:
- –Partial paralysis of lower extremities
- •Defective nerve supply to bladder
- •May develop joint deformities in utero
- •Dimple: may be spina bifida occulta
-
What is therapeutic mgmt?
- •Fetal surgery: new procedure with 4% mortality
- •Meningomyelocele:
- –Early closure within 24-72 hrs after delivery
- •Hydrocephalus management (shunt)
- •Management:
- –Multidisciplinary & multispeciality
- •Orthopedics, GU, GI, Infectious Diseases
-
How to manage GI fxn?
- •Neurogenic bladder dysfunction
- –Preserve renal function
- –Achieve optimal urinary continence
- •Tx of renal problems:
- –Treat UTIs
- –Clean intermittent catheterization
- –Meds to improve bladder storage & continence
- –Urinary diversion (Mitrofanoff)
- •Catheterizable channel created from the bladder through a stoma near the umbilicus
-
How to prevent trauma to sac?
- •Prevent trauma to sac
- –Keep moist (normal saline dressings)
- •Positioning:
- –Before surgery: prone & low Trendelenburg (head turned to side & up to feed)
- •General care:
- –Diapering contraindicated until after surgery—needs tactile stimulation
- –Skin care, ROM
- •Observe:
- –Head circumference, temp, signs of ICP
- •Latex allergy (up to 80%)
-
What is Muscular Dystrophies?
- •Genetic: gradual degeneration of muscle fibers
- –Progressive weakness & wasting of symmetric groups of skeletal muscles with disability & deformity
- •Pseudohypertropic (Duchenne) Muscular Dystrophy:
- –Most common (X-linked; almost only males)
- –Gene mutation that encodes dystrophin (skeletal muscle protein product)
-
What are clinical manifestations?
- •Most reach developmental milestones early in life (may have subtle delay)
- •3 - 7 yoa: muscle weakness
- –Difficulties with running, bicycling, climbing stairs
- –Later: abnormal gait (fall, Gower sign, waddle)
- •Pseudohypertrophy:
- –Progressive muscular enlargement from fatty infiltration
- –Result: contractures & deformities
- •Ambulation usually impossible by 12 yoa
-
What is Dx, Tx & Prognosis?
- •Dx:
- –Blood PCR for dystrophin gene mutation
- –Prenatal dx (12 wks gestation)
- –Serum creatine kinase ↑, muscle biopsy, EMG
- •Tx:
- –Maintain function as long as possible
- –Corticosteroids?
- –Prevent contractures
- •Prognosis:
- –Death (usually late teens/early 20s):
- •URI or cardiac failure
-
What is Botulism?
- •Toxin from anaerobic Clostridium botulinum
- •Most common source: improperly sterilized home-canned foods
- –Also: wound botulism, bioterrorism
- •CNS S&S:12-36 hrs after ingestion
- •Tx: IV antitoxin until paralysis abates
- •Nursing care: supportive
- •Ingest spores/cells of C. Botulinum—release toxins from colonies in GI tract
- •Culprit: honey (appears to be no common food source)
- •Peak: 2-4 months of age
- •S&S:
- –Constipation, generalized weakness & ↓ in spontaneous movement, lethargy, poor feeding
- •Dx: clinical suspicion; detect organism in stool (days)
- •Tx:
- –STAT IV botulism immune globulin (neutralize toxin & stops progression)
- –May need mechanical ventilation, IV feeds
- •Prognosis:
- –Mortality <2% if treated quickly
-
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What causes Intracranial Pressure?
Craniums volume must remain stable. There is a small window of compensation--further increase in volume results in rapid increase.
-
What do you do after a head injury?
Stabalize a child's spine after a head injury until a spinal cord injury is confirmed or ruled out.
-
What if a child is bleeding from the nose or ears?
Although bleeding from the nose or ears is uncommon in children, it needs further evaluation, & a watery discharge from the nose (rhinorrhea) that is positive for glucose (as tested with Dextrostix) suggests leaking of CSF from a skull fracture
-
What is LOC?
- •Assessment of LOC = earliest indicator of improvement or deterioration of neuro status
- –Alertness
- –Cognition
- •Unconsciousness:
- –Inability to respond to sensory stimuli & have subjective experiences
- •Coma:
- –Cannot arouse even w/painful stimuli
-
What is the Glascow Coma Scale (GCS)?
- •Objective LOC measure
- –Eye opening
- –Verbal response
- –Motor response
- •Value 1-5 to each category
- –Normal = 15
- –Coma = 8 or ↓
- –Deep coma = 3
- •Lack of response to painful stimuli = abnormal & should be reported STAT!
-
What are Vital Sign Changes with ↑ ICP?
- •Temperature:
- –Often↑, sometimes extreme
- •Blood pressure:
- –↑; attempt to bring more blood & O2 to injured tissue with a widening pulse pressure
- •Pulse:
- –↓; pressure on vagus nerve in the lower brain stem
- •Respiratory pattern:
- –Altered; pressure on respiratory center in the medulla
- •In children, actual changes in pulse & BP are more important than the direction of the changes
-
What are pinpoint pupils?
- Poisoning (opiate or barbiturate)
- Brainstem dysfunction
-
What are Widely Dilated & Fixed?
- After seizures or eye trauma, may be unilateral
- Pressure from herniation of the brain through the tentorium
- Fixed bilaterally > 5 minutes = brain damage
-
What is Unilateral fixed?
Lesion on the same side
-
What is Dilated & Noreactive?
Brainstem damage, hypothermia, poisoning (atropine substances), mydriatic drugs
-
What is considered a neurosurgical emergency?
Observation of asymmetric pupils or one dilated, unreactive pupil in a comatose child is a neurosurgical emergency that may require evacuation of an epidural hematoma!
-
What is Doll's Head Maneuver?
- Rotate head quickly from one side to the other
- Eyes should move together opposite the movement of the head
- Brainstem or occulomotor nerve damage if eyes move the direction of the head
- Don’t use with C-spine precautions!
-
What is Caloric Test/Oculovestibular Response?
- Irrigate external auditory canal with ice water
- Normally causes conjugate movement of the eyes toward the side of the stimulation
- Lost when pontine centers are impaired
- Painful procedure: never do on alert child!
-
What is Funduscopic Exam?
- •Papilledema occurs with ICP
- –Optic disc swelling, hemorrhage, absence of venous pulsations
- •Older children & adults
- •Takes 24-48 hrs
- •Examine for pre-retinal hemorrhages from acute trauma with intracranial bleeding
-
What is Decorticate/Decerebrate posturing?
- •Decorticate:
- –Flexion
- –Severe dysfunction of the cerebral cortex
- •Decerebrate:
- –Extension
- –Midbrain dysfunction
-
How do you monitor brain damage with ↑ ICP?
Hypoxia (RR < 4/min): brain damage
-
Suctioning and ICP?
Suctioning (or NG tube) through the nares is contraindicated, since there is a high risk of secondary infection & the probability of the catheter entering the brain through the fracture.
-
What is Syndrome of Inappropriate Antidiuretic Hormone?
- dec. urine volume
- Hyponatremia
- Restrict fluids
-
What id Diabetes Insipidus?
- inc. urine volume
- Hypernatremia
- Replace fluids
-
What is head trauma: coup/countrecoup?
- •Bruising at point of impact (coup)
- •Bruising where the brain collides away from impact (contrecoup)
- •Sudden deceleration: greatest cerebral injury at the point of impact (e.g. falling)
- •Severe compression of the skull can cause the brain to herniate into the tentorial opening
-
What is a concussion?
- •Transient & reversible neuronal dysfunction with instantaneous loss of awareness & responsiveness
- –Traumatically induced alteration in mental status
- –Hallmarks: confusion & amnesia
- •Short time period (min-hr)
- •Cause: shearing forces cause nerve fibers to stretch, compress & tear
- •Observe for neuro changes
-
What is a contusion & laceration?
- •Bruising/tearing of cerebral tissue
- •Contusion:
- –Petechial hemorrhages along brain at impact (coup) or lesion remote from the direct trauma (countrecoup)
- –May cause focal disturbances in strength, sensation or visual awareness
- •Laceration:
- –Caused by a penetrating wound or depressed skull fracture
-
What are fractures?
- •Pediatric skull ↑ flexible—fewer fx
- •Range of brain damage & arteries can tear
- •Linear:
- –Majority; overlying hematoma/soft-tissue swelling
- •Depressed:
- –Bone breaks, pushes in & tears the dura
- •Open:
- –Opening between skull & scalp or surfaces of the upper respiratory tract; ↑ infection
- •Diastatic:
- –Traumatic separations of cranial sutures (< 3 yoa)
-
What is Basilar Skupp Fracture?
- •Most serious type
- •Break in basal portions of the frontal, ethmoid, sphenoid, temporal or occipital bones
- •Battle sign:
- –Postauricular bleed in mastoid sinus
- •Raccoon eyes:
- –Bleed into frontal sinuses
- •May have CSF leak from nose or ears
- –Antibiotics used prophylactically
- •Associated with cranial nerve injuries
-
What are Complications of Head Injuries?
- •Hemorrhage
- •Infection
- –Watch for post traumatic meningitis: fever & ↑ drowsy w/basilar skull fracture
- •Edema
- –From tissue trauma
- •Tentorial herniation
-
What is Epidural Hemorrhage?
- •Blood accumulates between dura & skull
- •Bleeding usually arterial: rapid brain compression
- •Classic: momentary unconsciousness—normal—lethargy/coma
- –Seldom in peds!
- •May be symptom free for longer than 48 hrs
- •Uncommon <4 yoa
-
What is Subdural Hemorrhage?
- •Bleeding between dura & cerebrum
- •Cortical vein ruptures—spreads slowly, thinly & widely
- •Common in infants:
- –Birth trauma, falls, violent shaking
- –Peak: 6 months
- •May have high mortality & poor prognosis
- –May have developmental retardation & FTT
-
What is Posttraumatic Syndrome?
- •From structural complications from the head injury
- •Minutes to an hour after the injury
- •Last several days to several months
- •Post traumatic seizures may occur within 2 yrs of injury
- •Infants
- –Pallor
- –Sweating
- –Irritability
- –Sleepiness
- –May vomit
- •Adolescents
- –HA
- –Dizziness
- –Impaired concentration
- •Children
- –Behavioral disturbances
- –Sleep disturbances
- –Phobias
- –Emotional lability
- –Irritability
- –Altered school performance
- –Seizures
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What is Near Drowining?
2nd accidental cause of death in peds
- •Young children can withstand longer periods of submersion
- •Diving reflex:
- –Neuro response triggered by immersion of face in cold water
- –Blood shunts away from periphery & concentrates to the brain & heart
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How should near drowning be managed?
- •1st priority: restore O2 delivery
- •All should be hospitalized 12-48 hrs for possible respiratory distress & cerebral edema
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What are brain Tumors: Gliomas?
- –Affects supporting structures of the nervous system
- –Most common brain tumors in children
•S&S depend on anatomic location & size & child’s age
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What is Neuroblastoma "Silent Tumor?"
•Most common malignant tumor of infancy
•Younger the child = better prognosis
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What are intracranial infections?
- •Affects meninges (meningitis) &/or brain (encephalitis)
- •Main pathogens:
- –Bacterial
- –Viral
- –TB
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What are STAT signs of Meningitis?
–Purpura or petechial rash—may have meningococcemia—STAT medical attention!
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How to Diagnose meningitis?
- •LP: cell count, C&S, protein, glucose
- – WBC (polys)
- – protein
- •Infections ↑ permeability of blood-CSF barrier
- –¯ glucose
- •Compare with serum glucose if possible
- •Blood culture: may grow organism
- Mgmt:
- •Respiratory isolation until on IV antibiotics for 24 hrs
- •Priority: labs, LP, IV antibiotics
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What is Encephalitis?
- •50% cause—unknown
- –Direct invasion or postinfectious involvement of CNS after viral disease (e.g. herpes)
- •Onset: sudden or gradual
- •Nonspecific signs evolve to focal neuro signs (malaise, fever, HA, stiffness, tremors, seizures—coma & death)
- •Dx: same as meningitis, may have specific serologic test (e.g. West Nile)
- •Tx: mostly supportive, acyclovir for herpes
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