Pediatrics Neuro

children are top heavy, HUGE proportion to body, poor neck musckles

Anatomic differences between children's and adults' nervous

24 months (2 years)

how long does sutures stay unfused

posterior within first 2 months and then anterior is close between 12 and 18 months

when to the anterior and posterior fontanel close

LOC, cognitive function, cranial nerves, skull, pupils, vital signs, posture and movement, neck stiffness, pain

what is in a nero assessment

intracranial pressure (ICP)

with an altered LOC you want to look for signs of increased

sequential pattern (initial changes may be subtle, restless, or fussy, failure to soothe)

Decline in LOC often follows a

-confusion

-delirium

-lethargy

-stupor

-coma

altered LOC categories

lethargy

profound slumber in which speech and movement are limited. Arousable with moderate stimulation, but falls asleep easily once stimulation is removed

headache, visual disturbances, diplopia, N/V, dizziness, a slight change in vitals, pupils not reactive or equal, a slight change in LOC

early signs of ICP

bulging frontale, wide sutures, increased head circumference, dilated scalp veins, irritabile, high pitched, catlike cry

early signs of increase ICP specifically in infants

sunsetting eyes, a significant decrease in LOC, seizure, fixed/dilated pupils, Cushing triad

late signs of increased ICP

increased systolic BP (widened pulse pressure), bradycardia, and irregular respirations

cushing triad

seizure

A sudden surge of electrical activity in the brain that cause involuntary movement, and behavior and sensory alterations

• Symptoms depend on type of seizure and duration

partial seizures

caused by abnormal electrical brain function in one hemisphere or a specific area of the cerebral cortex.

simple and complex

types of partial seizures

Simple Partial (Focal) Seizure

a type of partial seizure

no LOC

lasts <30 sec

no post ictal phase confusion

no aura

limited to an isolated muscle group (fingers, arms, or legs)

Simple Partial (Focal) Seizure description:

complex partial seizure

2nd type of partial seizures

Altered behavior

• Unable to respond to environment

• Impaired LOC (regains in <5 min)

• Automatisms: unusual body movement without purpose -lip smacking or chewing

• Aura frequently occurs

• Postictal period: confusion and inability to recall event

complex partial seizure description

Generalized Seizures

Involve both sides of the brain at the sametime

Tonic-Clonic Seizure

most common generalized

tonic, clonic, postictal

three phases of tonic clonic seizure

last 10-20 seconds:

Stiffening of body and limbs, back arched

• Eyes roll upward

• LOC

• Mouth snaps shut (may bite tongue)

• Possible piercing cry

• Pallor

• Increased salivation

• Apnea leading to cyanosis

tonic phase of seizure:

last 30-50 seconds:

Clonic jerks of limbs, body, and head

• Foaming of the mouth

• Incontinence

• Gradual slowing of movements until stop

clonic phase of tonic clonic

30 min or longer:

Limbs and body limp

• Remains semiconscious - aroused with difficulty

• Confused for several hours

• Impairment of fine motor movements

• Lack of coordination

• May have headache, vomiting, visual, or speech difficulties

• Sleep for several hours

• Feels tired

• May complain of muscle soreness

• Do not recall seizure

postical state of tonic clonic

Brief altered state of consciousness

• LOC lasts 5 to 10 seconds

• Motionless

• Blank stare

• Do not recall episodes

• Immediately resumes previous activity

• May be mistaken for a learning problem or behavioral problem

• Onset between ages 4 to 12 years

• End by teenage years

Absence Seizures:

Also called "drop attacks"

• Onset is between 2 to 5 years of age

• Muscle tone lost few seconds = risk for fall

• Period of confusion follows

• May need to wear helmet

atonic seizures

Variety of seizure episodes

• Symmetric or asymmetric involvement

• Brief contractions of muscles/group of muscles• May not lose consciousness

• No postictal state

Myoclonic Seizures

Infantile spasms and Febrile seizures

Types of unclassified seizures

Infantile Spasms(AKA West Syndrome)

rare disorder of unknown origin and peaks around 3-7 months of age

Sudden, brief symmetric muscle contractions

• May cry before or after

• May occur in a cluster, up to 150 seizures

• Even with proper therapy, they can have long-term complications

infantile spasms:

Febrile Seizures

Associated with sudden spike in temperature

• Duration of 15 to 20 seconds

Status Epilepticus

Prolonged seizure activity lasting 30 minutes or longer or continuous seizure activity where child does not enter postictal phase

Phenobarbital, Dilantin, Tegretol, Depakote, Zarontin, Keppra

Seizure Medications

gum hyperplasia, sleepiness, decreased attention and memory, difficulty with speech, ataxia and diplopia (must monitor therapeutic levels)

side effects of these drugs:

2 years without medications. In most cases if seizures recur, they will happen within the first year of AED withdrawal.

A trial of medication withdrawal is often attempted for children who have been seizure free for 2 years or longer. Medications are tapered slowly, over a few months. Approximately 70% of children remain seizure free for

Stay with child - ensure SAFETY

• Maintain airway

• Supplemental oxygen

• Monitor vital signs

• Medication

• Provide emotional support and education

what to do with a seizure

Meningitis

Bacterial: prognosis depends on how quickly care is initiated

newborns and infants

greatest risk for meningitis

Streptococcus pneumoniae and Neisseria meningitides cause the majority of cases in the U.S

causative agents of meningitis

infections, injuries, and crowded living conditions

risk factors for meningitis

• fever (cold hands + feet)

• refuses to eat

• PETECHIAE like rash below the CHEST

• bulging fontanelle

• seizure

• unusual cry

• increased resp

S/S of meningitis in (think of ICP symptoms and what happens with meningitis when inflamed)

blood work (causative agent), Lumbar puncture, and CT or MRI (to see increased IOP/abscess)

Meningitis: Diagnostic Procedures

cloudy color, elevated WBCs, elevated protein (bacteria excretes) , decreased glucose level (bacteria eats it) , positive gram stain

Bacterial findings in CSF for a LP

isolate ASAP droplet precautions

what kind of precaution for meningitis pt

ampicillin, gentamicin, cefotaxime, penicillin G, vanc

Antibiotics that cross blood-brain barrier

ASAP

when to start antibiotics for bacterial meningitis

dexamethasone

most effective med for reducing neuro complicationswith Hib infection

Reye Syndrome

Acute encephalopathy

• Primarily affects the liver and brain

cause not understood

using aspirin products for fevers caused by viral infections

risk for reye

Lethargy, irritability

• Combativeness, confusion, delirium

• Profuse vomiting

• Seizures, Loss of consciousness

findings with reye synrdrome

Hydrocephalus

Imbalance between production and absorption of cerebrospinal fluid (CSF)

Rapidly increasing head circumference

• Full or bulging anterior fontanel

• Split skull sutures

•Bossing (protrusion) of frontal area; face disproportionate to skull size

• Difficulty holding head up

• Prominent or distended scalp veins

• Increased tone or hyperreflexia

• Irritability or crying

• Decreased appetite or poor feeding

• Fever

• Decline in LOC

early signs of hydrocephalus (think ICP)

Sunsetting eyes

• Apnea episodes

• Shrill, high pitched cry

late s/s of hydrocephalus

A catheter or shunt is placed in the ventricle and passes the CSF to the peritoneal cavity; CSF is regulated by a one-way valv

Hydrocephalus: Therapeutic Procedure