[9.1] Pediatric Nursing (Increased ICP, Seizure Disorder / Epilepsy, Bacterial Meningitis, Head Trauma, & Congenital Cardiovascular Disorders)

From Sir Archie Alviz' Lecture Last August 11, 2025

1. Increased ICP

2. Seizure Disorder / Epilepsy

3. Bacterial Meningitis

4. Head Trauma

What are the discussed neurological disorders of the pedia?

5 to 15 mmHg

What is the normal range of ICP?

>20 mmHg

What ICP value is life-threatening?

Cushing’s Triad (HyperBradyBrady)

• Hypertension

• Bradycardia

• Bradypnea

Triad to WOF in increased ICP and its components

b. Wide pulse pressure

Increased ICP

a. Narrow pulse pressure
b. Wide pulse pressure

30-40 mmHg

Normal range of pulse pressure

1. NO

   1. Bulging fontanels

2. YES

3. NO

   1. Increased HEAD circumference

4. YES

5. NO

   1. Projectile Vomiting

6. NO

   1. Diplopia

7. YES

8. NO

   1. Sunset Eyes

9. YES

10. YES

Identify if the following is a s/sx of increased ICP (YES or NO):

1. Sunken fontanels

2. High-pitched cry

3. Increased chest circumference

4. Headache

5. Scant Vomiting

6. Nystagmus

7. Pupillary Changes

8. Sundowning

9. Anorexia, nausea, weight loss

10. Seizures

Crying

• Comfort and properly timed feeding

Increased ICP (S/Sx): Bulging fontanels are aggravated by what? What should be done to avoid this?

a. Anterior Fontanel

Diamond

a. Anterior fontanel
b. Posterior fontanel

b. Posterior fontanel

Triangle

a. Anterior fontanel
b. Posterior fontanel

12 to 18 months

Increased ICP (S/Sx): When does the anterior fontanel close?

2-3 months

Increased ICP (S/Sx): When does the posterior fontanel close?

a. Anterior fontanel

Bigger

a. Anterior fontanel
b. Posterior fontanel

b. Posterior fontanel

Closes first

a. Anterior fontanel
b. Posterior fontanel

High-pitched cry

Increased ICP (S/Sx): Early sign of increased ICP

Headache

• Sasakit muna ang ulo nila bago sila iiyak nang high pitched

Increased ICP (S/Sx): Earliest/Initial sign of increased ICP

High-pitched cry

Increased ICP (S/Sx): Irritable cry; shrill cry

1. High-pitched cry

2. Irritability and agitation

3. Restlessness

4. Confusion

What are the early signs of increased ICP in the following age group?

1. Infant

2. Child

3. Adult

4. Geria

1. Tape measure

2. Increased head circumference

Increased ICP (S/Sx): What should always be at the bedside (1) to measure this s/sx of increased ICP (2)?

Every shift of q8 hours

Increased ICP (S/Sx): How often should the head circumference of a pediatric patient be measured?

Compression of medulla → Compression of the CTZ (Chemoreceptor Trigger Zone) d/t Cerebral Edema

Increased ICP (S/Sx): Explain why there is projectile vomiting among pediatric patients with increased ICP.

Cerebral Edema

There is 80-95% chance that increased ICP or vomiting in increased ICP is caused by this.

Skull X-ray or CT Scan

How is Cerebral Edema diagnosed in the ED?

Diplopia

Increased ICP (S/Sx): Double Vision

Inc. ICP = Inc. IOP → Optic Nerve damage → Blurring of vision

• → Blindness (latter stages)

Increased ICP (S/Sx): Explain why there is diplopia in pediatric patients with increased ICP.

PERRLA (Pupils Equally Round and Reactive to Light and Accommodation)

Increased ICP (S/Sx): What is the normal reaction of the pupils?

TRUE

TRUE or FALSE: PERRLA implies that there should be consensual eye movement

1. Brain damage (Uneven pupil size)

2. Shock

3. Narcotic overdosage

Increased ICP (S/Sx): Identify the cause of the following pupillary changes

1. Anisocuria

2. Dilated pupils

3. Constricted pupils

Sunset Eyes

Increased ICP (S/Sx): eyes are directed downward, with the iris covered by the lower eyelid

FALSE

• You should still assess further

TRUE or FALSE: If the pediatric patient’s pupils are widely distributed to the whiter portion, this rules out increased ICP.

Weight / Weight Loss

Increased ICP (S/Sx): This is an important general indicator of health among pediatric patients

1. Increased neuronal firing

2. Vomiting

Increased ICP (S/Sx): What are the two main reasons for the seizure of the pediatric patients?

1. Increased neuronal firing → erratic transmission of electrical impulses → Seizures

2. Vomit → decreased fluid levels → DHN → Increased temperature → Convulsions → Seizures

   1. Parang kotseng walang tubig, mag-ooverheat

Increased ICP (S/Sx): Explain the development of seizure based on its two main causes?

Semi-fowler’s (Dec ICP by the virtue of gravity)

Increased ICP: What should the patient’s position be?

Coughing and Sneezing

Increased ICP: What activities should be avoided?

1,200 - 1,500 mL/day

Increased ICP: How much fluid intake should be given?

FALSE

• It could aggravate the ICP due to increased fluids

TRUE or FALSE: Since dehydration is a cause for seizure in increased ICP, then the OFI should also be increased.

1, 2, 4, 6, 9

Which of the following are included in the pharmacotherapy for increased ICP among pediatric patients?

1. Diuretics

2. Decadron

3. Hydrochlorothiazide

4. Anticonvulsants

5. Benzodiazepines

6. Antacids

7. PPIs

8. Antiplatelets

9. Anticoagulants

10. Beta Blockers

a. Lasix (Furosemide)

Increased ICP (Pharmacotherapy): Localized

a. Lasix (Furosemide)
b. Mannitol

b. Mannitol

Increased ICP (Pharmacotherapy): Generalized

a. Lasix (Furosemide)
b. Mannitol

Both a and b

Increased ICP (Pharmacotherapy): K Wasting

a. Lasix (Furosemide)
b. Mannitol

a. Lasix (Furosemide)

Increased ICP (Pharmacotherapy): Loop / Loop of Henle

a. Lasix (Furosemide)
b. Mannitol

b. Mannitol

Increased ICP (Pharmacotherapy): Osmotic

a. Lasix (Furosemide)
b. Mannitol

Decadron (Dexamethasone)

Increased ICP (Pharmacotherapy): Prevent Cerebral Edema

Anticonvulsants

Increased ICP (Pharmacotherapy): Prevent/minimize seizure episodes

Anticonvulsants

Increased ICP (Pharmacotherapy): Muscle relaxants

Antacids

Increased ICP (Pharmacotherapy): Neutralizes Acidity

Magnesium (Magtatae)

Increased ICP (Pharmacotherapy: Antacids): Side effect is diarrhea

Aluminum (Alang Tae)

Increased ICP (Pharmacotherapy: Antacids): Side effect is constipation

1. Increased ICP → Increased Stress → Increased HCL Production

2. Dexamethasone → Gastric irritation (stomach easily ulcerated)

Both causes increased acidity

Increased ICP (Pharmacotherapy): Why are antacids indicated?

Anticoagulants

Increased ICP (Pharmacotherapy): Prevents clumping of blood

1. IV/SQ (ptt)

2. Oral (pt)

Increased ICP (Pharmacotherapy): Identify the route of the following and the lab parameter that should be monitored

1. Heparin

2. Warfarin

Increased ICP → Increased BP in the brain → High risk for blood vessel injury → Clotting

Increased ICP (Pharmacotherapy): Why are anticoagulants indicated?

Opiates and Sedatives

• Can cause cardiac and respiratory depression especially that RR and HR are down in the Cushing’s Triad

Increased ICP (Pharmacotherapy): What drugs are contraindicated? Why?

Seizure Disorder / Epilepsy

Caused by erratic transmission of electrical impulses

1. Grand Mal (Generalized)

2. Petit Mal / Absent

3. Jacksonian Seizure

4. Psychomotor

5. Febrile Seizure

6. Status Epilepticus

What are the types of Seizures?

1. Tonic-Clonic

2. Post-Ictal

Type of Seizure: What are the subtypes or parts of grand mal seizures?

a. Tonic

Type of Seizure (Grand Mal): Mild Contractions

a. Tonic
b. Clonic

b. Clonic

Type of Seizure (Grand Mal): Severe contractions

a. Tonic
b. Clonic

Supine/flat position and protect the head

During a seizure episode, the patient may experience d_______, s______, and u______. With that, what should be the position of the patient and what should you do?

Post-ictal

Type of Seizure (Grand mal): Exhaustion

Side-lying/Recovery to prevent aspiration

Type of Seizure: What should be the position during the post-ictal phase? Why?

Petit mal/Absent

Type of Seizure: Blank facial expression

Automatisms

• Lip-smacking

Type of Seizure (Petit Mal/Absent): Repeated purposeless behavior in petit mal. What is the most common of these?

Jacksonian Seizure

Type of Seizure: Tonic-clonic of a group of muscle leading to grand mal

Psychomotor

Type of Seizure: Not common among pediatric patients; more common among adults.

Psychomotor

Type of Seizure: Mental clouding and intoxication

Psychomotor

Type of Seizure: Delirium, Hallucinations, and Delusions leading to seizure

Febrile Seizure

• Hypothalamus not yet developed → Thermoregulation impaired → Temperature widely fluctuating

Type of Seizure: Common for those under 5.

• Why is it so?

Febrile Seizures

Type of Seizure: Associated with high levels of temperature

38.5 deg. C to 39 deg. C to 40 deg. C

• 42 deg. C; Paracetamol RTC

Type of Seizure: What range of temperature often leads to febrile seizure?

• What temperature leads to damage? What is the drug order for this?

Status Epilepticus

Type of Seizure: 30 minutes; Brain damage could occur

1. Medications

2. Surgery

Seizure Disorder: Main way to manage is through ______(1)______. If not effective, _____(2)_____.

1, 4, 5, 6

Seizure Disorder: Select all the medications indicated

1. Hydantoins

2. Antacids

3. Lithium

4. Benzodiazepines

5. Iminostilbenes

6. Valproates

7. Dexamethasone

Phenytoin

• Gingival Hyperplasia

Seizure Disorder: What is the most popular hydantoin and what should you watch out for?

Pinkish-red

Seizure Disorder: What urine color is expected when the patient is taking phenytoin?

Benzodiazepines

Seizure Disorder: Minimizes seizure episodes (relaxants). Ends in -pam/-lam

Iminostilbenes

Seizure Disorder: Prevent seizure reoccurrence

Carbamazepine

Seizure Disorder: What are the common Iminostilbenes?

Refractory Seizure

Seizure Disorder: What do you call reoccuring seizures?

Valproates

Seizure Disorder: Last resort seizure medications for children

Valproic acid

Seizure Disorder: What is the most common valproate used?

Hepatotoxicity

Seizure Disorder: What is the side effect of valproic acid?

Can cause neural tube defects (NTDs) especially in 1st semester (Organogenesis)

Seizure Disorder: Why is valproic acid not given among pregnant patients?

Neurectomy

Seizure Disorder: What is the surgery of choice?

Cranial Nerve

Seizure Disorder: Neurectomy is the surgical resection of the _______ involved in the seizure

FALSE

• This is considered the last resort because it can cause permanent damage/effects

TRUE or FALSE: Neurectomy is the 1st line of management for seizure disorders among pediatric patients to directly resolve the root cause and avoid future complications.

It depends on the assessment of the neurosurgeon

Seizure Disorder: What cranial nerve is resected in patients undergoing neurectomy?

Bacterial Meningitis

Bacterial infection of the meninges

b. Viral meningitis

Self-limiting; the patient can survive without any permanent effects

a. Bacterial meningitis
b. Viral meningitis

Lumbar Puncture

What is the main diagnostic tool for bacterial meningitis?

L3, L4, and L5

Bacterial Meningitis: What are the vertebrae or parts to be aspirated CSF from in lumbar puncture tests?

C-shape, fetal position, knee chest to access L3, L4, and L5

Bacterial Meningitis (Lumbar Puncture): What should be the position of the patient?

Genupectoral

What is knee-chest position also known as?

Clear

Bacterial Meningitis (Lumbar Puncture): What should be the normal result of a CSF analysis?

Cloudy

• There is elevated WBC (to fight Bacteria)

• There is elevated CHON (by-product or waste-product of bacteria)

Bacterial Meningitis (Lumbar Puncture): What should be expected of the CSF analysis if there is bacterial meningitis? Why?

Neisseria meningitidis

Bacterial Meningitis: What is the causative agent?

1, 2, 5, 7, 12

Bacterial Meningitis: Which of the following are signs and symptoms of bacterial meningitis?

1. Kernig’s Sign

2. Brudzinski’s Sign

3. Herman’s Sign

4. Cullen’s Sign

5. Nuchal Rigidity

6. Rovsing’s Sign

7. Seizures

8. Dunphy’s Sign

9. Blumberg Sign

10. Obturator sign

11. Psoas Sign

12. Opisthotonus

13. Torticolis

Pain in the hamstring, back, and neck

Bacterial Meningitis (Kernig’s sign): When you flex the knee, where should the pain be for it to be positive?

Pain in the neck and back

Bacterial Meningitis (Brudzinski’s sign): When you flex the nape, where should the pain be?