Special Diagnostic Procedures

lab tests: glucose, CBC, electrolytes, blood cultures if fever; evaluate for toxic substances, liver function

imaging: CT, MRI, echencephalography, ultrasound, nuclear brain sac, PET

lumbar puncture

EEG

xray (rule out skull fractures, dislocations; evaluate degenerative changes, suture lines)

Nursing Care of the Unconscious Child

the outcome and recovery of the unconscious child may depend on the level of nursing care and observational skills

emergency management

airway

reduction of ICP

monitor for signs and treat shock

Assessment Parameters

LOC

pupillary reaction

vital signs

frequency of assessment depends on condition: range from every 15 min to 2 hrs

are they awake, alert, looking around, recognize parents, eyes moving together, pin point pupils?

Pain management for the comatose child

signs of pain - hrt rt, resp rt, o2 sats

increased agitation and rigidity

pain increases ICP

alterations in vital signs

Drup therapies for pain

opioids

fentanyl + midazolam + vecuronium (sedation)

acetaminophen and codeine

Respiratory management

airway management is primary concern

cerebral hypoxia lasting more than 4 hours may cause irreversible brain damage

risk of aspiration of secretions

ICP Monitoring

indications for ICP monitoring

glascow coma scale <7 or <8 and in resp distress

deteriorating neuro status

Nursing care for child with increased ICP

patient positioning - HOB 15-30 degrees

avoid activities that may increase ICP

eliminate or minimize environmental noise

frequent head circumference checks - at least once a day

suctioning issues - can inc. ICP (suction as needed)

Nutrition and Hydrations

IV administration of fluids and parenteral nutrition

caution with overhydration

later begin gastric feedings via NG or GT

patient may continue to have risk of aspiration

Medications (as indicated)

osmotic diuretics for cerebral edema

antiseizure medications with or without sedatives

paralyzing agents

antipyretics

Nursing care needs

elimination

hygienic care

position and exercise

stimulation

family support

Hydrocephalus

Hydrocephalus Causes: Congenital

Stenoses of the aqueduct of Sylvius d/t malformation: 10%

Dandy-Walker malformation: 2-4%

Arnold-Chiari malformation type 1 and type 2

Agenesis of the foramen of Monro

Congenital toxoplasmosis

Bickers-Adams syndrome (congenital stenosis of aqueduct of Sylvius)

Hydrocephalus Causes: Acquired

mass lesions 20%

intraventricular hemorrhage

infections

increased venous sinus pressure

iatrogenic

idiopathic

Physical signs in Infants

vomit

dont eat

inactive

head is enlarged

scalp veins dilated

fontanels seem tense pressure 

suture lines may not line up correctly

setting sun: eyes drift down

Symptoms in children

slowing of mental capacity

headaches (initially in the morn)

neck pain

vomiting, more significant in morn

blurred vision

double vision

stunted growth and sexual maturation from third vent dilation

diff walking secondary to spasticity

drowsiness

Physical signs in children

papilledema

failure of upward gaze

macewen sign: a "cracked pot" sound is noted on percussion of the head

unsteady gait

large head: sutures are closed, but chronic increased ICP will lead to progressive abnormal head growth

unilateral or bilateral sixth nerve palsy

Treatment

medical: help dec production of CSF (Lasix)

emergent: lumbar puncture or tap (risk of herniating brain)

surgical: r/t tumor or growth - shunt placement

Craniosynostosis

premature fusion of cranial sutures in head

result in abnormal shape to head

can be associated with genetic syndrome but usually idopathic

Dx: prenatal ultrasound, xrays, MRI, CT

head circumference will be different or feel fontanels are not right size for age

Treatment: helmets for protection; surgery: neuro & plastic

Bacterial Meningitis

highest in neonates (less than 1 month)

also in 3 year olds and adolescents

very acute and quick onset

older - headache, fever, complaints of stiff neck

infants - very fussy, fever, trouble sleeping and feeding, can have seizures

can be subtle symptoms

Neonatal S/S

poor feeding

lethargy

irritability

apnea

listlessness

apathy

fever

hypothermia

seizures

jaundice

bulging fontanelle

pallor

shock

hypotonia

shrill cry

hypoglycemia

Infant/Children S/S

nuchal rigidity

opisthotonos

bulging fontanelle

convulsions

photophobia

headache

alterations of the sensorium

irritability

lethargy

anorexia

nausea

vomiting

coma

fever

Therapeutic Management

Dx: LP is the definitive diagnostic test

prevention - vaccine schedules up to date

isolation

airway maintenance

antimicrobial therapy

IV fluids

steroids

management of shock

control of seizures

chemoprophylaxis

Bacterial Meningitis: complications

seizures

SIADH

brain abscesses - pockets of pus in the brain

Long Term Sequelae

nerve deafness

cortical blindness

hemiparesis, quadriparesis

muscular hypertonia

ataxia

complex seizure disorders

mental motor retardation, learning disabilities

obstructive hydrocephalus

cerebral atrophy

Viral (Asceptic) Meningitis

mortality <1%, higher in neonates

many viruses cause

diagnosis: LP

treatment mostly supportive

Acyclovir

Viral Meningitis: S/S

fever

photophobia

mild meningeal irritation

irritability, disorientation, and altered mentation

signs specific to virus

neonate: poor feeding

LP: Bacterial vs Viral

Bacterial:

elevated WBC, polys

protein elevated

glucose decreased

Viral:

Sl. elevated WBC, lymphs

protein WNL or sl. increased

glucose normal

Seizures: Signs and Symptoms

change in LOC

involuntary movements

changes in perceptions, sensations (smell, vision, hearing, etc), behaviors

Etiology of seizures

idiopathic (no known cause)

genetic factors - family history, disorder

acquired - fevers, brain injury, hypoxia, cerebral palsy, bacterial infection (meningitis, sepsis)

Epilepsy

definition: ≥ 2 "unprovoked" seizures

idiopathic epilepsy: cause unknown

seizures are an indispensable characteristic of epilepsy

Major causes of seizures in children

birth injuries - hypoxic event, birth trauma, congenital defect

acute infections

in children older than 3 years, cause is usually idiopathic

Absence Seizures

formerly called petit mal or "lapses"

brief loss of consciousness

minimal or no change in muscle tone

almost always appear in childhood (4-12 years)

20 or more/day

no aura or warning

5-10 seconds in duration

usually dont fall

often misdiagnosed as ADHD

Atonic Seizures

sudden momentary loss of muscle tone

onset 2-5 years of age

may or may not have loss of consciousness

may have head drop down or forward (as if falling asleep) or can just fall to the ground (if persistent, have child wear helmet to keep safe)

Myoclonic seizures

sudden brief contractions of muscle group

may be single or repetitive

may not have loss of consciousness

often occur when falling asleep

may be nonspecific symptom in many CNS disorders

may be mistaken as exaggerated startle reflex

often seen with viral meningitis

if seizure, will not be able to flex head forward

Infantile Spasms

onset in first 6-8 months of life

cause: possibly d/t disturbance of central neurotransmitter regulator at specific phase of brain development

almost always associated with some form of MR or developmental delay

specific spike seen on EEG

twice as frequent in males

head and neck flex forward, knees drawn up (jackknife position)

may or may not have loss of consciousness

no postictal drowsiness

often associated with cerebral anomalies, anoxic brain injury, PKU

may also have microcephaly, tonic posture, or other abnormal movements

poor prognosis (mental and developmental)

treatment (ACTH, prednisone, antiseizure 2nd line) - watch for immune suppression (prednisone) and HTN

Status epilepticus

definition: seizure or series of seizures lasting more than 30 minutes without regaining premorbid LOC

treatment: intubation, IV access, close monitor in PICU

Status Epilepticus: Medications

Diastat (prefilled rectal syringe)

Versed (intranasal)

IV Ativan or Valproic Acid

IV loading with phenytoin for ongoing management

Pediatric Diagnosis of Seizure Disorders

ascertain type of seizure

determine the cause of the event

diagnositics

EEG, MRI, CT scans

LP to rule out meningitis

labs testing for electrolyte imbalance

history of illness prior to seizure activity, causes of seizures, getting worse, how long they last, how many times a day

Common Pediatric Seizure Triggers

tired

dehydration

sudden loud noises

bright flashing lights

extreme temp changes

fever (not necessarily how high the fever, but how quickly it rises in a period of time)

Febrile Seizures

cause unknown

usually in temps higher than 101.8

seizure occurs when temp is rising, not after

seizure usu over before arriving in emergency department

between 6 mo and 3 years, not uncommon up to 5 years

more common in males

rectal diazepam for kids who have frequent febrile seizures to be given at home

things to help keep fevers reduced

do not lower temp too quickly, can cause rebound seizure

follow up with history of seizures

teach parents about how to handle when child has seizure (positioning, not to put things in mouth)

Febrile Seizure Treatment

if lasts more than 5 minutes, call 911

prophylaxis with meds

if have focal or prolonged seizures

if have neurologic anomalies

if have first-degree relative has seizure history

in child less than 1 year old

if have multiple seizures in a 2-hr period

Pharmacologic Management

monotherapy is treatment of choice for pediatrics

start on low dose and have gradual increase of dose until seizure controlled or signs of toxicity

polypharmacy if uncontrolled with one drug

frequent monitoring of blood levels

never suddenly discontinue medication, needs to slowly wean off with tapered dose

Nursing Interventions

Observe and document episode

protect form injury: not able to knock against bedrails, against walls, need to be in safe place, lay on side, monitor vitals

stay calm

remain with child

privacy if possible

if child in hospital, have suctioning set up at bedside, pad bedrails, vitals after seizure (possibly first hour after seizure, then every other hour after)

Home management of seizures

CPR training for family members

rectal diazepam available for intractable seizures

activity restriction on individual basis

safety devices - helmets, no swimming alone, awareness of school, other caregivers

Primary Head Injuries

those injuries that occur at a time of trauma

include: contusions, intracranial hematoma

Subsequent Complications of head injuries

hypoxic brain injury

inc ICP

infection

cerebral edema

Concussion

transient and reversible

results from trauma to the head

instantaneous loss of awareness and responsiveness lasting for minutes to hours

generally followed by amnesia and confusion

Contusion and Laceration

terms used to describe visible bruising and tearing of cerebral tissue

Coup: bruising at the point of impact

Contrecoup: bruising at a site far removed form the point of impact

Skull fractures in children

great deal of force is required to produce a skull fracture in an infant

fracture on the underside of skull can tear the meningeal artery, causing severe hemorrhage with hypovolemia hypotension

Types of Skull Fractures

Linear - line fx

depressed - bone inward in several fx

compound - laceration of skin and fx of skull

basilar - tear of the dura

diastatic - separation of cranial sutures (wont see past age of 8)

Complications of head trauma

epidural hemorrhage

subdural hemorrhage

cerebral edema

Diagnostic Evaluation

assessment of ABCs

vital signs

neurologic exam for older child - able to follow commands, move extremities equally, trouble feeding, inconsolable

special tests: CT, MRI, behavioral assessment

good hx - hx matches findings of exam

Therapeutic management

care in hospital if severe injuries, loss of consciousness for several minutes, prolonged or continued seizures

NPO intially

possible surgical interventions