1. When does school age occur?
    • 6-12.
    • Shedding of first tooth-final tooth
  2. When does Puberty occurf?
    • Girls: 10
    • Boys: 12
  3. 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
  4. Who do kids socialize with?
    • Peer group
    • Club
    • Best friends (same-sex peers)
  5. What is bullying?
    • Physical or psychological abuse
    • Bully: defiant, antisocial
    • Victim: characteristics differ from norm, can develop LT depression & low self esteem
  6. 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
  7. 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
  8. What is the most common cause of severe injury or death?
    • MVA
    • Rear car seat is safest <13 yr
  9. CH 16: Adolescent
  10. When is Adolescence?
  11. 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
  12. When does physical growth occur?
    Final 20%-25% of height during puberty

    Most of the growth during a 24-36 month period growth spurt
  13. What is social development?
    • Acceptance by peers
    • A few close friends
    • Secure love of a supportive family
    • Seek mutual affection & equality with parents
  14. 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
  15. CH 19: COGNITIVE
  16. 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%
  17. 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
  18. 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
  19. 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
  20. 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
  21. 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
  22. What is mixed?
    • Interference with transmission of sound in the middle ear & along neural pathways
    • From recurrent otitis media
  23. What is Central auditory imperception?
    • No defects in conductive or sensorineural structures
    • Includes problems expressing the message into meaningful communication
  24. What are types of visual impairment?
    • Myopia
    • Hyperopia
    • Astigmatism
  25. What is myopia?
    Light rays fall in front of the retina

    Nearsighted (see near objects, but not far)

    Corrective lenses or surgery
  26. What is hyperopia?
    Light rays fall beyond the retina

    Farsightedness (see objects at a distance)

    Corrective lenses or surgery
  27. What is Astigmatism?
    Unequal curves in refractive apparatus

    Corrective lenses or surgery
  28. What is Amblyopia?
    Lazy eye

    Reduced visual acuity in one eye
  29. What is Strabismus?
    Cross eye

    Eye patch or sx
  30. What are cataracts?
    Opacity of the lens

  31. What is glaucoma?
    Increased intraocular pressure
  32. What is a common cause of blindness in children?
    Trauma: foreign objects, penetrating injuries, chemical burns, infections
  33. 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
  34. 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
  35. 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
  36. 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
  37. 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
  39. 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?
  40. 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
  41. 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
  42. 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.
  43. What are goals of therapy?
    • Reduction
    • Immobilization
    • Restore function
    • Prevent further injury
  44. 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
  45. What do you check with someone who has a plaster cast?
    Neurovascular checks a priority
  46. What do hot spots in a syntetic material cast mean?
    “Hot” spots after dry may mean infection
  47. 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!
  48. 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.
  49. 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
  50. 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
  51. What are types of DDH?
    • Dysplasia: mildest; delay in acetabular development
    • Subluxation: majority; partially displaced femur head
    • Dislocation
  52. What is treatment for DDH?

    • •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
  53. 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
  54. What is Metatarsus Adductus (Varus)?
    • •Most common congenital foot deformity
    • •Cause: abnormal intrauterine position
    • •Pigeon-toed gait
    • •Tx: manipulation & stretching or casting
  55. 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
  56. 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!
  57. 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?
  58. 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
  59. 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
  60. 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
  61. 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)
  62. CH 32: NEURO
  63. 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
  64. 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
  65. 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!
  66. 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
  67. 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!
  68. 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
  69. 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
  70. 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
  71. 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
  72. 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
  73. 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%)
  74. 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)
  75. 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
  76. 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
  77. 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
  78. CH 28: CEREBRAL
  79. What causes Intracranial Pressure?
    Craniums volume must remain stable. There is a small window of compensation--further increase in volume results in rapid increase.
  80. 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.
  81. 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
  82. 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
  83. 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!
  84. 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
  85. What are pinpoint pupils?
    • Poisoning (opiate or barbiturate)
    • Brainstem dysfunction
  86. 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
  87. What is Unilateral fixed?
    Lesion on the same side
  88. What is Dilated & Noreactive?
    Brainstem damage, hypothermia, poisoning (atropine substances), mydriatic drugs
  89. 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!
  90. 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!
  91. 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!
  92. 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
  93. What is Decorticate/Decerebrate posturing?
    • •Decorticate:
    • –Flexion
    • –Severe dysfunction of the cerebral cortex
    • •Decerebrate:
    • –Extension
    • –Midbrain dysfunction
  94. How do you monitor brain damage with ↑ ICP?
    Hypoxia (RR < 4/min): brain damage
  95. 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.
  96. What is Syndrome of Inappropriate Antidiuretic Hormone?
    • dec. urine volume
    • Hyponatremia
    • Restrict fluids
  97. What id Diabetes Insipidus?
    • inc. urine volume
    • Hypernatremia
    • Replace fluids
  98. 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
  99. 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
  100. 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
  101. 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)
  102. 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
  103. 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
  104. 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
  105. 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
  106. 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
  107. 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
  108. How should near drowning be managed?
    • •1st priority: restore O2 delivery
    • •All should be hospitalized 12-48 hrs for possible respiratory distress & cerebral edema
  109. 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
  110. What is Neuroblastoma "Silent Tumor?"
    •Most common malignant tumor of infancy

    •Younger the child = better prognosis
  111. What are intracranial infections?
    • •Affects meninges (meningitis) &/or brain (encephalitis)
    • •Main pathogens:
    • –Bacterial
    • –Viral
    • –TB
  112. What are STAT signs of Meningitis?
    –Purpura or petechial rash—may have meningococcemia—STAT medical attention!
  113. 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
  114. 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
  115. What are S&S of Ravies?
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