-
Brain hernia
Portion of the brain is displaced because of increased pressure inside skull
-
-
Which is better an open or closed head injury
Open (releives pressure from brain swelling)
-
Portion of brain in cranium total volume
80
-
CSP percent of cranium total volume
10%
-
Blood is what % of cranium total volume?
10%
-
Early sign and symptoms of head injury in an infant
- Bulging fontanel
- High pitched cry
- Distended scap vein
- Change in feeding
- Setting-sun sign (dowward deviation of the infant's eyes)
-
Early sign and symptoms of head injury in children
headache, nausea, vomiting, diplopia, seizures
-
Behavioral signs if ICP
- Irritability
- restlessness
- drwosiness
- diminished physical activy
- increased sleeping
- memory loss
- can't follow simple commands
- lethargy
-
Late signs of ICP
- Bradycardia
- Decreased LOC
- Decreased motor response
- Alterations in pupil size
- Decerebate or decorticate (outward feet, hands flexed on chest) posturing
- Papilledema (buling of the optic disc)
- Coma
-
Depressed cerebral function - in ability to resond to sensory stimuli and have subjective exeriences
Unconsciousness
-
State of unconsciousness which teh patient cannot be around even with pain
Coma
-
EARLIEST indicator of neurological status
LOC
-
Permantly lost function of teh cerebral cortex
PVS (persistant vegetative state)
-
Eyes follow objects by reflex
PVS
-
Limbs are spastic but withdraw from painful stimuli
PVS
-
-
Child may cry or maol (NO WORDS)
PVS
-
Eye opening GCS -
1-4 (4 best)
-
Verbal response GCS
1-5 (5 best)
-
Motor response GCS
1-6 (6 best)
-
below 6 on GCS
Bad...coma
-
Temp in coma
often elevated
-
If coma is toxic in origin, what happens to body temp?
hypothermic
-
High temp could also be caused by
- acute infection
- Heat stroke
- Salicylates
- Alcohol
- Barbituates,
- ICP
- subarachoid hemorrhage
-
Hypothalmic involvement related to coma can cause
increased or decreased temp
-
Pulse during coma
Variable, rapid, sow and bounding and feeble
-
BP during coma
normal, elevated or shock levels
-
Actual changes in BP during coma
are more important than the direction of the change
-
Increase of BP in a comatose patient may indicate
PAIN
-
Respirations during coma
slow deep irreglar
-
Breathing pattern during coma
irregular or periodic
-
irregular breathing during coma may precede
complete apnea
-
Breath odor can provide clues to
Ketosis, uremia (foul)
-
Skin during coma
important to assess for bites
-
Eyes during coma
Pinpoint in opiate or barbituate poisoning, also brainstem dysfunction
-
Dilated and reactive eyes seen after
seizures, and may only involve one side
-
Widely dilated and fixed pupils
Paralysis of cranial nerve III (100% morbidity)
-
Pupils bilaterally fixed for > 5 minutes
brainstem damage (neurologically devistated)
-
Dolls head maneuver
One side to other side, goal is to have eyes move opposite, absense my be brainstem damage or oculomotor damage III... odone byu physician
-
Who does Dolls' head maneuver
2 different specialty drs 24 hours apart.
-
Optic disc swelling, hemorrhage develops in
24-48 hours
-
Retinal hemorrhages seen in
acute trauma with intracranial bleeding
-
Rigid flexion, associated with lesions ABOVE the brainstem
Decorticate posturing
-
Rigid extension associated with lesions of the brainstem seen in
Decerebate posturing
-
Bebinski reflex significant if seen in children what age?
>18 mo
-
Lab values to look at RT cerebral function
-
Measures spinal fluid pressure
LP
-
Relieves ICP in an infnat w/out closuure of closed fontanels
Subdural tap
-
Detects electrical abnormalities/seqizures brain death
EEG
-
Horizontal and vertical cross sections at any axis...does not show blood flow
CT
-
Tissue discrimination, morphologic features of target structures
MRI
-
-
Chloral hydrate, what route?
PO elixer
-
Dose for chloral hydrate
75 - 100 mg/kg (max dose is 1 gram for infants 2 grams for children)
-
If child awake after 20 minutes of first dose of chloral hydrate, give
100 mg/kg up to a total of 1 gram for infants, 2 grams for children
-
Give at least 35 to 45 minutes before procedure
Chloral hydrate
-
Carry to room or sedate in tx room when using
Chloral hydrate
-
Are controversial in pain management of the comatose child
Opiods
-
Morphine, demerol, etc in comatose child not suggested due to
further depression of the CNS
-
Unrelieved pain can cause
ICP
-
Used for mild to moderate pain
Co-analgesics delivered via o/g
-
Nonpharmacologic interventions for pain management in the comatose child
dim lights, quiet environment, preventing jarring or sudden movmeent
-
Stimulation in comatose patient causes
Increase in ICP
-
First priority in respiratory managment in comatose patient
Establishment of airway
-
No oxygen beyond how long causes brain damage
4 min
-
Used to decrease drisk of aspiration and cardiac arrest for respiratory management
Positioning
-
Chest PT aloong with position changes every q hrs
2
-
Osmotic diuretics provide relieve up to
6 hours
-
Can be used in an emergency
Osmotic diuretecs
-
Mannitol usually given
IV infusion slowly
-
Can be given IV push in case of herniation
Mannitol
-
Need catheter for use of mannitol why?
extreme diuretic effect
-
Frequently accompanies CNS disease - brain injury, meningitis, brain tumor, etc.
SIADH
-
Scant quantities of urine
SIADH
-
Clients have hypOnatremia, hypOsmolality, overhydrated
SIADH
-
Tsx of SIADH
Restriction of fluids
-
Typically it self corrects
SIADH
-
May follow intercranial trauma
DI
-
-
Must replace fluids and monitor electoryte imbalance
DI
-
May have hypernatremia and hyperosmolality
DI
-
Give exogenous vasopressin (ADH) desmopresson for
DI
-
Meds for treatment of unconsious/comatose child with ICP
- Morphine
- Fentanyl
- Versed (produces amnesia, short half life)
- Paraytic agent
-
Only use barbituates when meds in the unconsciou comatose chilod with ICP
FAIL
-
HR or BP can idicate the need for more
dosing
-
Where does blood accmulate with epidural hemorrhage /hematoma
b/w dura and skull
-
Brain compressure in a head injury occurs
quickly
-
Can be sx free with a head injury for how long?
48 hours
-
Subdural hemorrhage bleeding between
dura and cerebrum
-
More common in children than epidural hemorrhage
subdural hemorrhage
-
occurs most frequenct in infancy, peaks at 6 months
subdural hemorrage
-
what provides relief in infants when client has subdrual hemorrhage
Subdural taps
-
Most common malignant solid tumor in children
neuroblastoma
-
higher incidence in males (tumor)
nuroblastoma
-
known as the silent tumor
neuroblastoma
-
Often diagnosed after metastasis
neuroblastoma
-
Radiation of neuroblastoma usually for stage ____ or greater
III
-
Radiation is used as emergency management of neuroblastoma when
compressing on the spinal column.
-
Infratentorial tumors are bad because
they affect cerabellum (posterior third of brain) and brain stem
-
Supratentorial tumors are located where?
Cerebrum, with better outcomes
-
Worst possible form of glimoa
glioblastoma multiform (GBM)
-
Vascular neoplasms with prominent areas of necrosis and hemorrhage
Glioblastoma multiform
-
What dx method to detect gliobastoma multiform
MRI, which shows blood flow
-
Glioblastoma typically 100%
Fatal
-
S&S of glioblastoma directly related to what?
Anatomic location and size
-
Most common symtoms of Glioblastoma are
- 1.) HA upon awakening
- 2.) Vomiting not related to feeding
- Often vague and overlooked. Needs excellent hx
-
Neuro changes with glioblastoma multiform
Ataxia, poor fine motor control + babinski reflex
-
Behavior manifestations of glioblastoma multiform
Irritability, fatigue, lethargy, bizzare B
-
Acute inflammation of the meninges and CNS
Bacterial meningitis
-
H influeinza Type B vaccine has decreased incidence of
Bacterial menengitis
-
Other bacteria causing bacterial meningtitis
- Streptocoscus pneumoniae
- Neisseria Meningitidis
- Nenates: E coli and group B strep
-
Majority of cases ofbacterial meningitis are between what age?
1 month and 5 years
-
Increased blood in the brain and edematous brain are problems seen with
Bacterial meningitis
-
Entire surface of brain covered with purulent exudate
Bacterial meningitis
-
Nucah rigidity and floppy presentation seen with
Bacterial meningitis
-
Purpuric or petechial rash are CLASSIC signs of
Bacterial meningitis
-
Nuchal rigidity is a CLASSIC sign of
Bacterila meningitis
-
Most definitive dx test off bacterial meningitis
LP
-
LP during bacterial meningitis will show elevated
WBC and protein
-
LP will show decreased ___________ with bacterial meningitis
Glucose
-
Clear LP fluid from meningitis
Viral
-
Child must be isolated if they have
Bacterial meningitis
-
What do you give for H influenza during bacterial meningitis
Dexamethasone for H. Influencza
-
Learning disabilities and decreased IQ are residual effects of
Bacterial memngitis
-
What nerve should be evaluated, and when during bacterial meningitis
VIII at 6 month follow up (ears, due to ototoxicity of gent and vanco)
-
Test question?
LP tap then immediately give antibiotics
-
Viral meningtitis as also known as
viral meningitis
-
DX of viral meningtitis
septic work-up, LP
-
until viral mengitis confirmed, treat as
bacterial
-
Life threatening encephalopty with accompanyintg microvascular fatty deposits in the liver and kidneys
Reye's syndrome
-
Usually follws a viral illness, varicella and influenza
Reye's syndrom
-
link between ASA and what?
Reyes
-
Mild viral infection, signs of recovery noted 24 to 48 hours, but after initial improvement condition may worsen
Reyes
-
After vomiting, changes in LOC
Reyes
-
How fast to death after onset of Reyes?
2-3 days, however downward progression can stop fast
-
Inflammatory process of CNS; produces altered function of portions of the brain and spinal cord
Encephalitis
-
Cuased usually by viral, and herpes accounts for 30% of cases
Encephalitis
-
DX can be mabde by appreanace of IgM antibody to HSV type I in CSF and serum
Encephalitis
-
Early use of what IV antibiotic reduced mortality and morbidity in encephalitis?
acyclovir
-
Complicatition of AIDS
HIV encephalopathy
-
Symptom of an underlying disease
epilepsy/seizure
-
Is every seizure a sign of epilepsy?
NO
-
What is epilepsy?
Chronic seizure disorders, recurrent and unprovoked
-
Focal sezure
Paritalo, frontal temp, pariet, does not cross corpus collosum
-
May have auro
Focal/partial seizure
-
Generalized siezure
No focal onset, no auro, both hemispheres, lose consciousness!!
-
Tonic/clonic movmeents
Generalized seizures
-
Tonic is
unconsciousness, stiffness, muscles contract
-
Clonic
Alternates b/w contractions and sustained stiffness
-
-
-
DX for siaures
EEG, complte physical and neuro exam, lab, CT and PREFER MRI
-
Refractory seizures
don't go away
-
Goa of AED
Raise threshold and prevents seizures
-
AED can be used as monotherapy or?
Adjuctive
-
-
Primary AEDs, first generation (affect the liver) can be used as mood stabilizers
- Carbamazepine
- Dilantin
- Cerebyx
- Valproic acid
-
Can gradually decrease dose of AED's if
2 years seizure free/normal EEG
-
Which seizure type not well controlled?
Refractory
-
seizure lasting longer than 30 minutes
Status epilepticus
-
TX of status epilepticus
Diazepam or larazeman (benzos), IV, if theycontinue cerebex and dilantin or distate rectally
-
Absence seizures
interpreted as inattention/daydreaming/onfused with ADHD
-
Tegretol/Carbamazepine therapuetic level
4-12
-
Phentoin/Dilantin terhapeutic level
10-20
-
Phenobarbital therapeutic level
15-40
-
Depakote therapeutic level
50-100
-
Side effects of AED depakote
- alopecia and loose hair
- Increase appetite
-
SE of Dilantin
Gingival hyperplasia
-
SE Lamictal
Steven's Johnsons
-
SE of many first generation AEDs
Lethargy/malaise
-
Triggers of epilepsy
- Illenss (strepP
- dehydration
- fatigue
- hyperventilation
- hypoglycemia
- changes in temp
- viral/bact epilep
-
Age for febrile siezures
6 mo to 3 years
-
minutes for febrile sez
5 minutes
-
During the rise of a fever, may cause
Febrile
-
TX of febrile seizures
- Valium (anticonvulsant)
- Antipyretic
-
Do not institute prohylactic AED therapy
Febrile
-
Tepid baths for febrile
Not effective...makes things worse
-
Caused by increase production, impaired absorption or block of flow of CSF
Hydrocephaly
-
Results in massive amount of CSF within cerebral ventricles
Hydrocephaly
-
Congenital or aquired
Hydrocephaly (head trauma, shaken baby)
-
Early sign of Hydrocephaly
Head circumphrance...rapid increase
-
Tense full bulging fontenael
Hydroeph
-
Late sign of hydroceph
- Apnea
- High pitched cry,
- VOMITING
-
Daily mresuremtn of head
Therapuetic for hydroceph
-
VP shunt used for
Hydrocephaly
-
Problems with shunt
INFECTION AND MALFUNCTION
-
Shunt obstruction
leads to increased ICP
-
TX infections of shunts with
massive doses of IV antibiotic therapy
-
Keep child fat after
shunt placement so ICP not rapidly reduced
-
Monitor for abdominal distention , which can lead to peritonitis or postop ileus
After shunt placement
-
Guillian Barre caused by
Virus, usually pertussis
-
Guillian Barre usually caused brom a GI or respiratlory illness abou thow many days prior to onset
10
-
How long for recovery of GB?
2 years
-
GB weakness, asymm or symmetrical
symmetrical
-
Labs in GB
Not useful in dx
-
Protein levels in CSF in GB
Not definative
-
-
May need anticoagulants and SCD's, plasmaphoresis and/or IVG
GB
-
TX for headaches
Topomax if severe, otherwise NSAIDS
-
Pigmentented patches called cafe au lait maules
neurofibromatosis (6 or more, that increase with age)
-
Bening tumors that grow around nerves under the skin
Dermal neurofibromas
|
|
