N2130 - Children and Neurological Dysfunction (Lecture 7)

What should you know about objectives?

Describe the various modalities for assessment of cerebral function. Differentiate between the states of consciousness. Formulate a care plan for the child with altered intracranial pressure.

What should you know about objectives?

Differentiate types of seizures. Demonstrate an understanding of the manifestations of a seizure disorder and the management of a child with such a disorder. Understand and describe strategies for managing seizures in children.

What should you know about objectives?

Describe potential complications of the child with a head injury. Outline a care plan for the child with concussion.

What should you know about assessment of cerebral function?

Most information about neurological status can be obtained by observation and indirect measurements (i.e., infants and young children: observe spontaneous and elicited reflex responses) Children <2 years require special evaluation as they are not able to respond to directions to elicit specific responses. Developmental level

What should you know about assessment of cerebral function?

Delays or deviations from expected milestones may indicate risk for neurological issues or developmental delay Family history Esp. pregnancy and birth history for potential intrauterine influences on development of central nervous system (i.e., maternal infections, cigarette, alcohol or drug use)

What should you know about assessment of cerebral function?

Health history Apgar scores, age of developmental milestones, trauma/injuries, illnesses, encounters with animals/insects, ingestion or inhalation of neurotoxins Physical examination

What should you know about assessment of cerebral function?

Level of alertness, size and shape of head, fontanels, sensory responses, motor function (tone, posture, strength), symmetry of movements, respirations, dysmorphic facial features, behaviors, reflexes, cranial nerves

What should you know about increased intracranial pressure (iicp)?

The cranium’s total volume of brain (80%), cerebrospinal fluid (10%) and blood (10%) must remain approximately the same at all times

What should you know about increased intracranial pressure (iicp)?

Increases in intracranial pressure (ICP) may be caused by tumors, accumulation of fluid within the ventricular system, bleeding or edema of cerebral tissues

What should you know about increased intracranial pressure (iicp)?

Early signs and symptoms may be subtle.

What should you know about increased intracranial pressure (iicp)?

As pressure increases, signs and symptoms become more pronounced, and level of consciousness (LOC) deteriorates.

What should you know about increased intracranial pressure (iicp)?

Clinical Manifestations of Increased Intracranial Pressure in Infants and Children — — Infants — Children — Late Signs

What should you know about increased intracranial pressure (iicp)?

-tense, bulging fontanel -separated cranial sutures -irritability and restlessness -drowsiness/increased sleeping -high-pitched cry -increased fronto-occipital circumference -distended scalp veins -poor feeding -setting-sun sign — -headache -nausea -forceful vomiting -blurred vision -seizures -indifference, drowsiness -diminished motor performance -increased sleeping -inability to follow simple commands — -bradycardia -decreased motor response -decreased sensory response to painful stimuli -alterations in pupil size/reactivity -flexion or extension posturing -Cheyne-Stokes respirations -papilledema -decreased consciousness -coma

What should you know about altered states of consciousness?

Consciousness implies awareness Alertness—An arousal-waking state Cognitive power—Ability to process stimuli and produce verbal and motor responses

What should you know about altered states of consciousness?

Altered consciousness can fall along the spectrum of brief to indefinite Unconsciousness is depressed cerebral function—the inability to respond to sensory stimuli and have subjective experiences Coma is unconsciousness where the patient cannot be aroused even with powerful stimuli

What should you know about levels of consciousness?

Earliest indicator of changes in neurological status

What should you know about levels of consciousness?

Parents may be helpful during assessment

What should you know about levels of consciousness?

Infants and young children may not respond the same in an unfamiliar environment or to an unfamiliar voice as they would to a parent or caregiver

What should you know about levels of consciousness?

Motor activity, reflexes, and vital signs are not parallel to the depth of comatose state

What should you know about box 50.2:?

Levels of Consciousness Full consciousness—Awake and alert; oriented to person, place, and time; behaviour appropriate for age Confusion—Impaired decision making

What should you know about box 50.2:?

Disorientation—Disorientation to time and place, decreased level of consciousness Lethargy—Limited spontaneous movement, sluggish speech, drowsy, falling asleep quickly Obtundation—A severe reduction in LOC; the child arouses with very strong stimulus but is close to a comatose state

What should you know about box 50.2:?

Stupor—Remaining in a deep sleep, responsive only to vigorous and repeated stimulation or moaning responses to stimuli Coma—No motor or verbal response or extension posturing to noxious (painful) stimuli Persistent vegetative state (PVS)—Permanently lost function of the cerebral cortex; eyes following objects only by reflex or when attracted to the direction of loud sounds, all four limbs spastic but can withdraw from painful stimuli, hands showing reflexive grasping and groping, face grimacing, some food may be swallowed, groaning or crying but without uttering any words

What should you know about coma assessment?

Glasgow Coma Scale (GCS) (Fig. 50.2 in text) Standardized description and interpretation of degree of depressed consciousness Eye, verbal, and motor response Decrease in GCS score indicates deterioration

What should you know about coma assessment?

Unaltered LOC would score highest with 15 Scores of 8 or below is generally accepted as definition of a coma The lowest score, 3, indicates severe head injury and deep, unresponsive coma or even brain death

What should you know about coma assessment?

Neurological determination of death Complete cessation of brain function Irreversibility of condition

What should you know about neurological examination?

Descriptions of behaviours should be simple, objective, and easily interpreted. For example: “Drowsy but awake and oriented to person, place and time” “Sleepy, but arousable with vigorous physical stimuli. Pressure to nail base of right-hand results in upper extremity flexion/lower extremity extension”

What should you know about neurological examination?

Vital signs Temp often ↑ acute infection, ingestion of medications or substances, or intracranial bleeding) Pulse may be rapid, slow and bounding or feeble (weak/thready)

What should you know about neurological examination?

BP may be normal, elevated or at shock levels For assessment purposes, actual changes in pulse and BP are more important than direction of change Respirations are often deep and heavy (i.e., Cheyne-Stokes). Rapid respirations less common.

What should you know about neurological examination?

Sedatives, after seizures, or cerebral infections *Best to describe what is being observed rather than placing a label on it (i.e., Cheyne-Stokes) because terms are often misinterpreted

What should you know about neurological examination?

Skin Color, temperature, turgor Signs of injury (lacerations, ecchymosis or hematoma) Needle marks, bites, ticks Evidence of toxic substances may be found on hands, face, mouth and clothing Eyes Pupil size and reactivity

What should you know about neurological examination?

Pinpoint pupils—poisoning (i.e., opiates or barbiturates), brain stem dysfunction Widely dilated and reactive pupils—post seizures (may only be one side), eye trauma Widely dilated fixed pupils—paralysis of cranial nerve III secondary to pressure from herniation of the brain

What should you know about neurological examination?

Unilateral fixed pupil—usually suggests a lesion on the same side Bilateral fixed pupils >5 mins—usually assumed to be brainstem damage Dilated and nonreactive pupils are also seen in hypothermia, anoxia, ischemia, certain medication poisoning

What should you know about neurological examination?

Sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency

What should you know about neurological examination?

Motor function Spontaneous activity, posture, response to painful stimuli Provides clues to the location and extent of cerebral dysfunction

What should you know about neurological examination?

Lack of response to painful stimuli is abnormal and should be reported immediately Even subtle movements should be noted Asymmetrical or absence of movement may suggest paralysis

What should you know about neurological examination?

The deeper the comatose state, there is little or no spontaneous movement. Tremors, twitching and muscle spasms are common. Once again, observations should be described rather than labelled Posturing Flexion—severe dysfunction of cerebral cortex or lesions above the brainstem

What should you know about neurological examination?

Extension—dysfunction at level of midbrain or lesions to the brainstem Posturing may not be evident when child is relaxed, can usually be elicited with stimulation Important to describe the stimulus needed to provoke the response (i.e., painful stimuli, suctioning, etc.)

What should you know about neurological examination?

Reflexes In young infants, the Moro, tonic neck and withdrawal (to painful stimuli) are 3 reflexes that demonstrate healthy neuro status

What should you know about special diagnostic procedures?

Laboratory tests may help delineate the cause of unconsciousness Blood glucose, urea, CBC and lytes, liver function tests (LFTs), toxicology screening, platelets, blood lead levels Electroencephalogram (EEG)

What should you know about special diagnostic procedures?

Measures electrical activity in the brain through electrodes applied to scalp Lumbar punctures allow for examination of cerebrospinal fluid When toxic encephalopathy or infection is suspected

What should you know about special diagnostic procedures?

Assessment of evoked potentials (auditory and visual) Measure electrical activity in the brain in response to stimulation of sight or sound Imaging (Computed tomography (CT) and magnetic resonance imaging (MRI)

What should you know about special diagnostic procedures?

Scans both soft tissue and solid matter Young children may require sedation for imaging procedures Important to prepare child and family for procedure ahead of time

What should you know about seizures?

Most common treatable neurological disorder in children Manifestation of seizures depends on region of brain in which they originate Occur with wide variety of CNS conditions

What should you know about seizures?

Seizure is a SYMPTOM, of an underlying disease process Caused by excessive and disorderly neuronal discharges in the brain Infections, intracranial lesions or hemorrhage, metabolic disorders, trauma, genetic disorders Determined by site of origin

What should you know about seizures?

May include unconsciousness, or altered consciousness, involuntary movements; and changes in perception, behaviours, sensations, and posture.

What should you know about epilepsy?

Two or more unprovoked seizures occurring more than 24 hours apart A single seizure even should not be classified as epilepsy and generally not treated with long-term antiepileptic medications. Approx. 1% of the Canadian population has epilepsy

What should you know about epilepsy?

Approx. 50% of cases of childhood epilepsy will have seizures disappear completely Important to classify the seizure once occurs. Classification of Epileptic Seizures

What should you know about seizures: etiology?

Acute symptomatic

What should you know about seizures: etiology?

Associated with acute insult (i.e., head trauma or meningitis) Remote symptomatic

What should you know about seizures: etiology?

Associated with prior brain injury such as encephalitis, meningitis, or stroke Cryptogenic No clear cause

What should you know about seizures: etiology?

Idiopathic Genetic in origin

What should you know about seizures: pathophysiology?

Abnormal electrical discharges may arise from: central areas in the brain that affect consciousness, may be restricted to one area of the cerebral cortex producing manifestations of particular anatomical focus, or

What should you know about seizures: pathophysiology?

may begin in a localized area of the cortex and spread to other portions of the brain Begins with a group of neurons in the CNS that, because of excessive excitation and loss of inhibition, amplify their discharge simultaneously Sodium, potassium, calcium and chloride channel ions greatly influence neuronal activity

What are the key points about seizures: classifications and manifestations?

Seizure classification: Focal (partial) seizures

What are the key points about seizures: classifications and manifestations?

Local onset, starts in an area of cells on one side of the brain

What are the key points about seizures: classifications and manifestations?

Patient typically maintains awareness, but may be non-verbal during seizure Generalized seizures

What are the key points about seizures: classifications and manifestations?

Involves both hemispheres without local onset

What are the key points about seizures: classifications and manifestations?

Often accompanied by loss of awareness Unknown onset seizures

What are the key points about seizures: manifestations?

Seizures have a beginning, middle, and end. Symptoms during a seizure usually occur the same way or similar each time, are episodic (come and go), and may be unpredictable. Beginning

What are the key points about seizures: manifestations?

Prodrome: some may experience feelings, sensations, or changes in behaviour hours or days before a seizure, not considered part of a seizure Aura: first symptom of a seizure, often an indescribable feeling, other times may be easily described as a change in feeling, sensation, thought, or behaviour that is similar each time a seizure occurs Middle (ictal phase)

What are the key points about seizures: manifestations?

Period of time from first symptoms (including aura) to end of seizure activity Sometimes visible symptoms last longer than seizure activity on an EEG End (postictal) Some recover immediately, others take minutes to hours to feel like themselves again

What are the key points about seizures: manifestations?

Type of seizure and part of the brain impacted affects recovery period

What are the key points about common manifestations before, during and after a seizure — — —?

— Before a Seizure — During a Seizure — After a Seizure

What are the key points about common manifestations before, during and after a seizure — — —?

Awareness, Sensory, Emotional or Thought Changes — Déjà vu Smells, sounds, tastes Visual loss or blurring “Strange” feelings Fear/panic Pleasant feelings Racing thoughts — Loss of awareness (“black out”), confusion, feeling spacey, memory lapses Distracted, daydreaming Loss of consciousness Unable to hear Unusual smells, tastes Loss of vision, blurry vision, flashing lights Visual hallucinations Numbness, tingling, electric shock feelings, out of body sensations — Slow to respond Tired, confused, memory loss Difficulty talking or writing Feeling fuzzy, lightheaded, dizzy Feeling depressed, sad, upset Scared, anxious Frustrated, embarrassed, ashamed

What should you know about common manifestations before, during and after a seizure — — —?

Physical Changes — Dizzy or lightheaded Headache Nausea or other stomach feelings Numbness or tingling in part of the body — Difficulty talking Unable to swallow, drooling Repeated blinking/eye movements or staring Lack of movement or muscle tone Tremors, twitching, jerking Repeated non-purposeful movements (lip-smacking, repeated movements of hands, dressing/undressing, walking, running) Convulsions Loss of bladder/bowel control Biting of tongue, clenched jaw — Injuries, bruises, cuts Potential head injury if fell during seizure May feel tired, exhausted, or sleep for minutes-hours Headache or other pain Nausea or upset stomach Thirsty General weakness or weak in one part or side of body Urge to go to bathroom or loss of bowel/bladder control

What should you know about seizures: diagnostic evaluation?

determine whether seizures are epileptic or nonepileptic events and determining underlying cause, if possible differentiate epilepsy from other brief alternations in consciousness/behavior Thorough health history, skilled observations, diagnostic testing

What should you know about seizures: diagnostic evaluation?

Labs for WBC (infection), glucose (r/o hypoglycemia), toxicology screen CT, MRI, EEG EEG is obtained for most children with seizures EEG most useful for evaluating risk of recurrent seizures and diagnosing type of seizure

What should you know about seizures: diagnostic evaluation?

A normal EEG does not r/o seizures as EEG is only a surface recording representing approx. 1hr of time

What are the key management or nursing-care points for seizures: therapeutic management?

Medication therapy Antiepileptic medications Reduce the responsiveness of normal neurons to the sudden, high-frequency nerve impulses Dose gradually increased until seizure activity is controlled, or maximum recommended dose has been reached

What are the key management or nursing-care points for seizures: therapeutic management?

Multiple medications may be required Common antiepileptic drug side effects: Changes in mood/behaviour, vision changes, ataxia Side effects often subside

What are the key management or nursing-care points for seizures: therapeutic management?

CBC, urinalysis, LFTs obtained at regular intervals as antiepileptic medications may impact organ function When seizure medication is decreased it is done gradually over weeks/months Sudden withdrawal can cause seizures of greater intensity and duration

What are the key management or nursing-care points for seizures: therapeutic management?

Ketogenic Diet High-fat, low-carb, adequate protein Consumption of such a diet forces the body to shift from using glucose as the primary energy source to using fat, and the individual develops a state of ketosis

What are the key management or nursing-care points for seizures: therapeutic management?

All foods and liquids child consumes must be carefully weighed and measured Vitamin supplementation is required with this diet Vagus Nerve Stimulation Originally a palliative treatment for patients with uncontrolled seizures

What are the key management or nursing-care points for seizures: therapeutic management?

Currently adjunct therapy for >12 years of age with focal onset seizures unresponsive to medications Programmable signal generator implanted subcutaneously in the chest Electrodes underneath the skin deliver electrical impulses to the left vagus nerve (cranial nerve X)

What are the key management or nursing-care points for seizures: therapeutic management?

Device is activated using a magnet at the onset of a seizure

What are the key management or nursing-care points for seizures: therapeutic management?

Surgical Therapy Indicated when seizures are caused by hematoma, tumor, or other cerebral lesion Only reserved for those with epilepsy if persistent seizures occur despite trials of 3 antiepileptic medications, alone or in combination

What are the key management or nursing-care points for seizures: therapeutic management?

Focal resection—removal of epileptic zone Hemispherectomy—removal of all or most of one hemisphere Corpus callosotomy—separation of the connections between the two hemispheres in the brain to prevent seizure activity by blocking epileptic discharges

What are the key management or nursing-care points for seizures: therapeutic management?

Surgery may result in a decrease in the frequency and severity of seizures, a decrease in antiepileptic medication, and an improvement in QoL

What should you know about status epilepticus (se)?

Medical emergency SE is continuous convulsive activity or recurrent generalized convulsive seizure activity without regaining consciousness For generalized tonic-clonic seizures, treatment should be initiated at 5 minutes.

What should you know about status epilepticus (se)?

After 30 minutes of continuous seizure activity risk for long-term sequalae such as neuronal injury is higher For focal seizures with impaired awareness, treatment should be initiated at 10 minutes. Nursing care management: CABs of life support Administration of oxygen Gaining IV access Ensure safety

What should you know about status epilepticus (se)?

Assessment, documentation

What should you know about status epilepticus (se)?

Lorazepam (buccal), or midazolam (IM, buccal, intranasally), and diazepam (rectally) are quick, effective and safe treatments for pre-hospital treatment of SE Respiratory depression is a potential adverse effect requiring close monitoring Lorazepam (IV), or midazolam (IV or IM) are equally recommended as first-line medication of choice for treatment of SE in hospital

What should you know about status epilepticus (se)?

If seizures are not controlled effectively with these benzodiazepines, IV loading with fosphenytoin, phenytoin, or phenobarbital is usually necessary fosphenytoin, and phenytoin may cause cardiac arrythmias, bradycardia, and hypotension such that continuous B{ and ECG monitoring is recommended during infusion Children may also receive an antiepileptic medication or general anesthesia with continuous infusion of midazolam, propofol, or pentobarbital if seizures continue despite medication

What should you know about drug — indication for use — reactions?

Benzodiazepines Lorazepam Diazepam Midazolam — Reduce anxiety Induce sedation, relax muscles, and inhibit seizures Treat alcohol and drug withdrawal symptoms. — “Hypotension, respiratory depression, sedation” (CPS, 2016)

What should you know about drug — indication for use — reactions?

Anti-epileptic drugs Fosphenytoin — Generalized convulsive status epilepticus Prevention of seizures during neuro surgery — “Decreased risks compared with phenytoin” (CPS, 2016) Rapid IV may cause hypotension Severe ataxis, CNS toxicity, confusion, paradoxic excitement, nystagmus, nervousness

What should you know about drug — indication for use — reactions?

Anti-epileptic drugs Phenytoin — Tonic-clonic and partial seizures — “Hypotension, bradycardia, arrhythmia” (CPS, 2016)

What should you know about drug — indication for use — reactions?

Anti-epileptic drugs Phenobarbital — Tonic-clonic seizures and partial seizures Usually combined with other drugs — “Respiratory depression (especially if benzodiazepine has been used), hypotension, sedation” (CPS, 2016)

What are the key management or nursing-care points for nursing care: general observations during a seizure?

Describe Order of events (before, during and after) Duration of seizure Onset Time of onset Significant precipitating events (i.e., missed medication dosage, illness, stress, sleep deprivation, menses)

What are the key management or nursing-care points for nursing care: general observations during a seizure?

Behaviour Change in facial expression Cry or other sound Stereotypical or automatic movements Position of eyes, head, body, extremities

What are the key management or nursing-care points for nursing care: general observations during a seizure?

Unilateral or bilateral posturing of one or more extremities Movement Change of position, if any Site of commencement – hand, thumb, mouth, generalized Tonic-clonic phases Lack of movement or muscle tone of body part or entire body

What are the key management or nursing-care points for nursing care: general observations during a seizure con’t?

Face Colour change – pallor, cyanosis, flushing Perspiration Mouth (position, deviation to one side, teeth clenched, tongue bitten, frothing, bleeding) Lack of expression

What are the key management or nursing-care points for nursing care: general observations during a seizure con’t?

Asymmetric expression Eyes Position—straight ahead, upward or outward, conjugate or divergent gaze Pupils—size, equality, reaction to light Respiratory effort Presence and length of apnea Other Incontinence

What are the key management or nursing-care points for nursing care: general observations during a seizure cont’d?

Postictal observations Duration of postictal period State of consciousness Orientation Arousability Motor ability

What are the key management or nursing-care points for nursing care: general observations during a seizure cont’d?

Any change in motor function Ability to move all extremities Paresis or weakness Speech Sensations Pain or discomfort

What are the key management or nursing-care points for nursing care: general observations during a seizure cont’d?

Sensory impairment

What are the key management or nursing-care points for nursing care: reminders for seizure management?

It is impossible to physically stop a seizure once it has begun The nurse must remain calm, stay with the child, and keep the child from harm If child is standing or seated, ease them down to the floor

What are the key management or nursing-care points for nursing care: reminders for seizure management?

If child is in a wheelchair, they should remain in the chair Place pillow or folded blanket under their head Remove eyeglasses If vomiting occurs, turn child to one side

What are the key management or nursing-care points for nursing care: reminders for seizure management?

Never attempt to restrain the child, put anything in the child’s mouth or give any foods/liquids Suctioning of the oropharynx may be necessary, ensure suction equipment is accessible and working Vital signs should be taken side rails raised when child is sleeping or resting, side rails and other hard objects should have padding

What are the key management or nursing-care points for nursing care: reminders for seizure management?

waterproof mattress or pad on bed/crib

What should you know about fever?

Most common symptom of pediatric illness Fever (hyperpyrexia)