peds exam 3 (neuro)

seizures

rapid firing of neurons in the brain that leads to kids not being aware or able to interact with the world around them

• symptoms of something else happening

types of seizures

• febrile

• infantile

• focal

• drop/atonic

• myoclonic

• absent

• generalized tonic-clonic

febrile seizures

• never had a seizure before (1st time w no existing seizure disorder)

• fixing fever may not stop seizure but they won’t have any more in the future

infantile seizure

looks like startle reflex

focal seizures

start in 1 area of brain and causes activity in that area

• can become general tonic-clonic in the same episode

drop/atonic seizures

lose balance suddenly and fall

• have to wear helmets

myoclonic seizure

sudden jerking

absent seizure

• quick and unnoticeable

• hardest to recognize

generalized tonic-clonic seizure

may have moaning, stiffening, and jerking

aura

having a feeling that a seizure is coming on

postictal phase

• how do ppl act post-seizure?

• usually: sleepy and out of it

VS in seizures

• decreased RR

• increased BP

goal with anti-epiletics

• goal: get them down to only 1 med and taper all the others down

• anti-epileptics slow everything down and make kids lethargic

• usually trial and error on how many meds they have to take

• when 1 med works, we slowly stop other or let them grow out of their dose

seizure precautions

• side rails up

• padded bedrails

• low bed

• pad floor with a mat incase they fall OOB

• make sure O2 NC doesn’t wrap around them (if applicable)

• put them on their side (usually you can’t)

• turn chin to side

• suction (for aspiration)

• have O2 ready

• clean area of anything that might hurt them

• time seizure and remember what happened

• alert band or necklace at all times

seizure precaution: turn chin to side

• don’t hold it there

• prevent aspiration

seizure precaution: time seizure and remember what happened

• if a seizure goes over 5mins, they have status epilepticus and need rescue meds

• ensure safety and have family monitor time so they know when to intervene at home

seizure rescue meds

nasal valium

• if you’re in a room with the seizing pt, don’t leave room to get med; have someone else get them

education for meds with seizures

• have rescue meds at all times

• there are also daily maintenance meds

therapeutic management for seizures

fosphenytoin

fosphenytoin

Used for seizures bc its compatible w dextrose 

neuro exam

• Level of consciousness (LOC)

• posture

• Motor function

• Sensory function

• Cranial nerves

• Reflex testing

• Vital signs

neuro exam: LOC

• Consciousness

• unconsciousness

• coma

• altered LOC

consciousness

• implies awareness

• The ability to respond to sensory stimuli and have subjective experiences

2 components of consciousness

• Alertness

• Cognitive power:

2 components of consciousness: alertness

an arousal-waking state

• ability to respond to stimuli

2 components of consciousness: cognitive power

ability to process stimuli and produce verbal or motor responses

unconsciousness

• Depressed cerebral function

• Inability to respond to sensory stimuli and have a subjective experience

levels of consciousness

• Full consciousness

• confusion

• disorientation

• lethargy

• obtundation

• stupor

• coma

• persistent vegetative state

full consciousness

Awake and alert, oriented to time, place, and person;

behavior appropriate for age

confusion

Impaired decision making

disorientation

Confusion regarding time and place; decreased LOC

lethary

Limited spontaneous movement, sluggish speech,

drowsy, falling asleep quickly

obtundation

Arousable with stimulation

stupor

Remaining in a deep sleep, slow response to vigorous and repeated stimulation or moaning responses to stimuli

coma

a state of unconsciousness from which the patient cannot be aroused even with powerful stimuli

Persistent vegetative state

– Permanently lost function of the cerebral cortex

– Eyes follow objects only by reflex or when attracted to the direction of loud sounds

– All limbs are spastic but withdraw from painful stimuli

– Reflexive grasp and groping of hands

– Facial grimace

– May be able to swallow some foods

– May groan or cry but utter no words

altered LOC

Altered LOC can be momentary or extend for hours, days, or indefinitely

assessment of LOC

• LOC is determined by observations of the child’s responses to the environment

• Parents can be useful in helping with this exam (how do they respond to parents calling name?)

• ≥ 3 years should be able to give their name

• Young children may not be cognizant of place or time (ask abt time of day; breakfast/ daytime; ask abt who’s with them)

neuro assessment: how to determine LOC

• pupils (especially when they don’t react to light relfexes; look for doll eyes)

• interactive and paying attention

• clapping and flinch reflex

• reactive

• appropriate verbal response

neuro assessment: how to determine LOC: pupils

• Pinpoint pupils: poisoning and brainstem dysfunction

• Dilated and reactive pupils: after seizures and trauma

• Dilated and fixed pupils: paralysis of CN 3 due to pressure from herniation of brain; seen with hypothermia, anoxia, ischemia

• Unilateral fixed pupil: lesion on same side

doll eye maneuver

normal: The eyes move in the opposite direction of the head turn. They stay focused straight ahead

abnormal: The eyes move along with the head, staying fixed in their sockets

neuro assessment: how to determine LOC (interactive and paying attention)

meaningful interaction w people and environment is good

neuro assessment: how to determine LOC (reactive)

• reactive to touch, speech

• follow ppl or objects

neuro assessment: Muscle tone

extended and flaccid posture= decreased tone

neuro assessment: cranial nerve 2

Yunger kid: shine light in eye (should blink) 

Older kid: chart reading 

neuro assessment: cranial nerve 3

Infant: shine light see if they follow 

Older: 6 cardinal gazes 

neuro assessment: cranial nerve 5

Infant: rooting and suck relfex 

Older: touch forehead or cheeks or watch chewing 

neuro assessment: cranial nerve 7

Infant: look at facial expression 

Older: puff cheeks

neuro assessment: cranial nerve 8

Infant: blink when hear sound 

Older: whisper test 

neuro assessment: cranial nerve 9 & 10

Infant swallow and gaga 

Older gag reflex 

neuro assessment: cranial nerve 11

Older kids: shrug shoulders 

Younger not rlly tested 

neuro assessment: cranial nerve 12

Older kids: stick tongue out 

Younger: sucking and swallowing 

neuro assessment: reflexes (young infants)

• Moro

• tonic neck

• withdrawal reflexes are key to neurologic health

glascow coma scale (GCS)

• A scale used to standardize the description and interpretation of the degree of depressed consciousness​

• Assesses eye opening, verbal response, and motor response​

• A decrease in the GCS score indicates deterioration of the child’s condition​

how to assess GCS

• look at things that happen spontaneously

• <1 year= open eyes to noise

• spontaneous movement

• younger kids= do they smile at mom?

GCS scoring

• Highest score of 15 = unaltered LOC​

• ≤ 8 = coma​

• lowest score of 3 = deep coma

• A decrease in the GCS score indicates deterioration of the child’s condition​​

Reyes syndrome: patho

encephalophy in brain (swelling and irritation in brain)

causes of Reyes syndrome

•  bc of viral infection (Chicken pox or flu)

• Risk w those 2 viruses 

• Aspirin causes it as well 

rabies

• Can cause encephalopathy and great deterioration 

• caused by getting bit by a rabid animal

tx for rabies

IVIG

• Will die without getting immunoglobulin

botulism

• Can come from honey or baby formula 

• Cosmetic uses: botox 

• Kids can become paralyzed 

tx of botulism

Immunoglobulin: baby BIG 

neural tube

structure in utero when baby spine is being formed as well as protection around it

neural tube defect

protection around it spinal cord grows abnormally

• Usually in lumbar= no control of legs and bladder/bowel control 

• High up in the spine= more problems (may not be able to breathe when it gets high enough) 

prevention of neural tube defect

folic acid

types of neural tube defects

• Anencephaly

• Myelodysplasia

neural tube defect: anencephaly

most serious congenital NTD in which both cerebral hemispheres are absent; not compatible with life

neural tube defect: Myelodysplasia:

• malformation of the spinal cord and canal

• Midline defects involving the failure of the osseous spine to close are called spina bifida

  • Spina bifida occulta

  • Spina bifida cystica

types of spina bifida cystica

■ Myelomeningocele

■ Meningocele

spina bifida cystica: myelomeningocele

Spina bifida cystica

• prone to having chiari malformation

char malformation

• brain tissue extends into spinal cord

• structural defect that causes hydrocephalus 

• Head gets rlly big 

dx of neural tube defects

• prenatally (CVS, ultrasound, elevated AFP)

• after birth from physical exam findings, CT, MRI, and US of brain and spinal cord

brain death protocol

• apnea test

• Usually transport these pts at night bc there's less traffic 

brain death protocol: apnea test

• done at 2 diff times w 2 physicians assessing child at same time

• Kid on vent or can't breathe on own (if they're spontaneously breathing; they're not brain dead) 

• We take away vent and see if kid can spontaneously breathe on their own 

• then we get ABG to see CO2 and O2 blood test

brain death protocol: apnea test (ABG to see CO2 and O2 blood test)

• PaCO2: at least 60  

• Rise at least 20 points higher than baseline 

• If yes, brain dead (organ donation questions for fam) 

patho of hydrocephalus

• CSF is produced and reabsorbed in ventricles 

• Too much CSF means accumulating in ventricles= ventricles get bigger and  

2 types of hydrocephalus

• Communicating and flow around 

• Non communication= no flow 

communicating hydrocephalus

Usually a reabsorption problem 

Therapuetic management of hydrocephalus

shunting to drain fluid (VP shunt)

EVD placememt

• The position of the EVD would be maintained at the level of the external auditory meatus (tragus) 

• Bc ear is a high point of body and is working w gravity (CSF drains slow which is what we want) 

• Don't lay kid on side w EVD bc it can accidentally press button and cause fluid to drain 

how does the placement of a VP shunt help with hydrocephalus?

• Lots of tubing (back of ear w buttons you can manually take fluid out of brain and into peritoneal cavity 

• Drains fluid 

• Reabsorbs  

s/s of hydrocephalus

• Irritability (bc of increased ICP) 

• Increased head circumference rapidly 

• Anterior fontanel slightly bulging 

• Tachycardia 

• Fever 

• Increased BP 

• Emesis 

• Head lag 

• Decreased feeding 

dx tests for hydrocephalus

• CT (looks at ventricle size) 

• LP (looks at CSF fluid to determine infection) 

• look for signs of increased ICP

s/s of increased ICP in infant

• Tense, bulging fontanelle

• Widened sutures

• Irritability and restlessness

• Drowsiness

• Increase sleeping

• High-pitch cry

• Poor feeding

• Setting-sun sign

s/s of increased ICP in child

• Headache

• Nausea

• Forceful vomiting

• Diplopia, blurred vision

• Seizures

• Indifference, drowsiness

• Decline in school performance

• Lethargy

normal CSF pressure

15 mmHg

nursing care for increased ICP

• Keep head positioned midline with the head of bed elevated 15-30°

• Avoid activities that can cause pain or emotional stress

• minimize noise

• suction only as needed

• routine cleansing and mouth care

• strict I&O

traumatic brain injury

Injury involving the scalp, skull, meninges, or brain as a result of trauma

patho is related to force of impact

3 major causes (listed in order) of traumatic brain injury

– Falls

– Motor vehicle injuries (almost exclussively the cause in <2)

– Bike injuries

physical impacts from trauma

• acceleration

• deceleration

• deformation

brain shape in trauma

• Coup (point of impact)

• Contrecoup (point brain collides with that is far removed from point of impact)

cerebral palsy

A group of permanent disorders of the development of movement and posture, causing activity limitation, that are attributed to nonprgressive disturbances that occurred in the developing fetal or infant brain

• Can develop postnatally (meningitis, encephalitis, trauma)

how is cerebral palsy characterized

• abnormal muscle tone and coordination

• Most common permanent physical disability of childhood

classifications of cerebral palsy

• Spastic (Pyramidal)

• Dyskinetic (Nonpastic, Extrapyramidal)

• Ataxic (Nonpastic, Extrapramidal)

• mixed type

spastic cerebral palsy

• persistent primitive reflexes

• positive Babinski

• ankle clonus

• exaggerated stretch reflexes

• eventual contractures

• diplegia

• hemiplegia

• hypertonicity

• Impairment of fine and gross motor skills

dyskinetic cerebral palsy

• Athetoid

• Dystonic-slow, twisting movements of the trunk or extremities; abnormal posture

• imperfect speech

dyskinetic cerebral palsy: athetoid

• chorea (involuntary, irregular, jerking movements)]

• characterized by slow, wormlike, writhing movements that involve the extremities, trunk, neck, facial muscles, and tongue

dyskinetic cerebral palsy: imperfect speech

drooling and dysarthria

• oral muscles involved

ataxic cerebral palsy

• Wide-base gait

• Rapid, repetitive movements performed poorly

• Disintegration of movements of the UE when the child reaches for objects

mixed type cerebral palsy

Combination of spastic CP and dyskinetic CP