Cerebral Dysfunctions

Learning Objectives

  • Understand the pediatric differences associated with anatomy and physiology of the neurological system (Review on your own).

  • Choose appropriate assessment guidelines and tools to examine infants and children with altered levels of consciousness and Increased Intracranial Pressure (ICP).

  • Determine appropriate nursing interventions for brain injuries.

  • Differentiate types of intracranial infections: bacterial meningitis, viral meningitis, encephalitis in infants and children.

  • Identify various types of seizures and describe nursing management for each.

  • Describe different types of treatment modalities for seizure disorders.

  • Understand the care of the child with hydrocephalus.

The Brain

Anatomy

  • The brain is protected and surrounded by cerebrospinal fluid (CSF).

  • It consists of three sections:

    • Cerebrum

    • Cerebellum

    • Brainstem

Autoregulation

  • Also known as self-regulation.

  • It allows cerebral arteries to change diameter in response to changes in cerebral perfusion pressure.

  • Autoregulation can be impaired by:

    • Trauma

    • Ischemia

    • Increased intracranial pressure (ICP).

  • How Autoregulation of Cerebral Blood Flow Happens:

    • Adjusts diameter of blood vessels.

    • Ensures consistent cerebral blood flow (CBF).

    • Only effective when mean arterial pressure (MAP) is between 70 and 150 ext{ mmHg}.

Increased Intracranial Pressure (ICP)

Definition

  • A life-threatening condition characterized by an increase in any of the three components of the skull:

    • Brain Tissue

    • Blood

    • Cerebrospinal Fluid (CSF) (e.g., hydrocephalus).

  • The brain, while well protected, is vulnerable to increased pressure that may accumulate within the cranium.

  • As pressure increases, signs and symptoms become more pronounced, leading to a deterioration in level of consciousness (LOC).

  • Early Signs and Symptoms may be subtle.

Nurses Assessment Parameters for Increased ICP

  • Indicators:

    • LOC (Level of Consciousness)

    • Pupillary reaction

    • Vital signs

  • Frequency of assessment: Depends on condition; ranges from every 15 minutes to every 2 hours.

Clinical Manifestations of Increased ICP

In Infants

  • Signs:

    • Irritability

    • Poor feeding

    • Vomiting

    • High-pitched cry

    • Difficulty soothing

    • Fontanels: Tense, bulging

    • Cranial sutures: Separated

    • Eyes: Setting-sun sign

    • Scalp veins: Distended

In Children

  • Signs:

    • Headache

    • Forceful vomiting

    • Seizures

    • Drowsiness, lethargy

    • Diminished physical activity

    • Inability to follow simple commands

Late Signs of Increasing ICP

  • Symptoms:

    • Bradycardia

    • Decreased motor response to command

    • Decreased sensory response to painful stimuli

    • Alterations in pupil size and reactivity

    • Extension or flexion posturing

    • Decreased consciousness

    • Coma

ICP Monitoring

  • Indications for ICP monitoring:

    • Glasgow Coma Scale (GCS) score of less than 8.

    • Traumatic brain injury with abnormal CT scan.

    • Deteriorating neurologic condition.

    • Subjective judgment regarding clinical appearance and response.

  • Types of ICP Monitors:

    • Intraventricular catheter

    • Subarachnoid bolt (Richmond screw)

    • Anterior fontanel pressure monitor.

Special Diagnostic Procedures for Increased ICP

  • Laboratory Tests:

    • Electroencephalography (EEG)

    • Lumbar puncture

    • Assessment of evoked potentials (auditory and visual)

  • Imaging:

    • Radiography (to rule out skull fractures, dislocations; evaluate degenerative changes, suture lines)

    • Computed Tomographic (CT) scan

    • Magnetic Resonance Imaging (MRI)

Nursing Activities for Increased ICP

  • Patient Positioning:

    • Avoid neck vein compression.

    • Provide alternating-pressure mattress.

    • Elevate head of the bed 30 degrees.

  • Avoiding activities that may increase ICP:

    • Eliminating or minimizing environmental noise.

    • Monitoring suctioning issues.

  • Nutrition and Hydration for Increased ICP:

    • Intravenous administration of fluids and parenteral nutrition.

    • Avoidance of overhydration.

    • Gastric feedings via nasogastric or gastrostomy tube.

    • Continued monitoring for aspiration.

Care Management of Increased ICP

  • Thermoregulation

  • Elimination

  • Hygienic Care

  • Positioning and Exercise

  • Stimulation

  • Regaining Consciousness

  • Family Support

  • Medications (as indicated):

    • Antibiotics for infectious processes.

    • Corticosteroids for inflammation and edema.

    • Sedatives or antiepileptics.

    • Sedation or amnesic anxiolytics.

    • Barbiturates (controversial).

    • Paralytic agents.

Coma Assessment

  • Glasgow Coma Scale (GCS): It assesses eye, verbal, and motor responses.

  • A decrease in GCS score indicates deterioration in student status.

  • Brain death requires:

    • Complete cessation of brain function.

    • Irreversibility of condition.

Altered States of Consciousness

Definition

  • Consciousness implies awareness:

    • Alertness: An arousal-waking state.

    • Cognitive Power: The ability to process stimuli and produce responses.

    • Altered Consciousness can range from brief to indefinite.

    • Coma: Unconsciousness with no arousal possible.

Levels of Consciousness

  • Earliest indicators of changes in neurological status can be noted by parents during assessment.

  • Motor activity, reflexes, and vital signs may not correlate with the depth of a comatose state.

Levels of Consciousness (Descending Order)

  • Full Consciousness: Awake and alert.

  • Confusion: Impaired decision-making.

  • Disorientation: To time and place.

  • Lethargy: Sluggish speech.

  • Obtundation: Arouses with stimulation.

  • Stupor: Responds only to vigorous and repeated stimulation.

  • Coma: No motor or verbal response to noxious stimuli.

  • Persistent Vegetative State: Permanent loss of function of the cerebral cortex.

Neurologic Examination

  • Involves assessment of:

    • Vital signs

    • Skin

    • Eyes

    • Motor function

    • Posturing

    • Reflexes

Nursing Care of the Unconscious Child

  • The outcome and recovery of an unconscious child may depend on the level of nursing care and observational skills needed.

  • Emergency Management Includes:

    • Airway management.

    • Reduction of ICP.

    • Treatment of shock.

Respiratory Management in the Comatose Child

  • Primary Concern: Airway management.

  • Cerebral hypoxia lasting over 4 minutes may cause irreversible brain damage.

  • CO2 retention causes:

    • Vasodilation.

    • Increased cerebral blood flow.

    • Increased ICP.

  • Gag and cough reflexes may be minimal, increasing the risk of aspiration of secretions.

Head Injury

Definition and Etiology

  • Head injury can refer to injuries of the scalp, skull, meninges, or brain due to mechanical force.

  • Three Major Causes of Brain Damage in Childhood:

    • Falls

    • Being struck by or striking an object

    • Motor vehicle injuries

  • Prevention Strategies:

    • Safety gates/fall prevention.

    • Seat belt use.

    • Use of safety helmets.

Pathophysiology of Head Injury

  • The force of intracranial contents may not be absorbed by the skull and musculoligamentous support.

  • Children are especially vulnerable to acceleration-deceleration injuries due to:

    • Larger head size in relation to body.

    • Insufficient musculoskeletal support.

Primary Head Injuries

  • Occur at the time of physical trauma, including:

    • Skull fracture

    • Contusions

    • Intracranial hematoma

    • Diffuse injury

  • Complications Include:

    • Hypoxic brain injury

    • Increased ICP

    • Cerebral edema.

Types of Head Injuries

Concussion

  • An alteration in neurologic or cognitive function, which may occur with or without loss of consciousness.

  • Symptoms are transient and reversible, often followed by amnesia and confusion.

Contusion and Laceration

  • Contusion: Visible bruising.

  • Laceration: Tearing of tissue.

  • Coup: Bruising at the point of impact.

  • Contrecoup: Bruising at a site distant from the point of impact.

  • Multiple sites of injury may be possible.

Fractures

  • The immature skull can withstand greater deformation before fracture.

  • To produce a skull fracture in an infant, the force must be extreme.

  • Types of fractures:

    • Linear

    • Depressed

    • Comminuted

    • Basilar

    • Open

    • Growing.

Complications of Head Trauma

  • Epidural Hemorrhage: Bleeding between the skull and the dura.

  • Subdural Hemorrhage: Bleeding between the dura and the arachnoid membrane.

  • Other hemorrhagic lesions: subarachnoid hemorrhage.

  • Cerebral Edema: Often associated with traumatic brain injury, leads to increased ICP and risk of herniation.

Sequelae to Traumatic Brain Injury

  • Postconcussion Syndrome: Symptoms like headaches or cognitive changes.

  • Posttraumatic Headaches.

  • Posttraumatic Seizures.

  • Hydrocephalus.

Diagnostic Evaluation of Head Trauma

  • Initial Assessment:

    • Detailed history.

    • Assessment of airway, breathing, and circulation.

    • Evaluation for shock.

    • Neurologic examination (LOC assessment).

    • Assessment of vital signs.

    • Special Tests:

    • CT scan

    • MRI

    • Behavioral assessment.

Therapeutic Management of Head Trauma

  • Children with severe injuries, LOC for several minutes, or prolonged/continued seizures require hospital care.

  • Nothing administered orally at first (NPO).

  • Surgical Therapy may be necessary in some cases.

  • Prognosis: Varies based on the extent of the injury.

Interprofessional Care Management

  • Frequent assessment of:

    • Vital signs

    • Neurologic status

    • LOC

  • Provide analgesia and sedation as needed.

  • Perform careful observation and recording of any changes.

  • Family Support is crucial during recovery.

  • Rehabilitation may be needed post-injury.

Prevention of Submersion Injury (Near Drowning)

  • A significant cause of accidental death in children, can occur in a small quantity of water (even a pail).

  • Near Drowning: Survival for at least 24 hours after submersion.

Pathophysiology of Drowning

  • Hypoxia: Results in pulmonary edema, atelectasis, and airway spasm.

  • Aspiration and Hypothermia are also critical factors (
    Increased risk is due to a large surface area compared to body mass).

Symptoms

  • Symptoms can relate to the duration of drowning and neurological status.

Therapeutic Management of Drowning

  • Emergency Resuscitative Efforts at the scene.

  • Management based on degree of cerebral insult.

  • Aspiration Pneumonia is a frequent complication, leading to hospitalization for observation.

  • Prognosis: Best predictor is the duration of submersion.

Care Management of Drowning

  • Care for the child depends on the condition.

  • Assist parents in coping with feelings of guilt and anxiety related to prognosis.

  • Prevention education for avoiding submersion injuries is essential.

Intracranial Infections

CNS Response Limitations

  • The central nervous system (CNS) has a limited response to injury; assessing the cause requires laboratory studies to identify the agent.

  • Inflammation can affect the meninges, brain, or spinal cord.

Bacterial Meningitis

Definition

  • Acute inflammation of the meninges and cerebrospinal fluid (CSF).

  • Incidence: Decreased since the introduction of the "Hib" vaccine in 1990.

Etiology

  • Caused by various bacterial agents, including:

    • Streptococcus pneumoniae

    • Neisseria meningitidis

    • Group β streptococci

    • Staphylococcus aureus

    • Escherichia coli

Clinical Manifestations

  • In Children and Adolescents:

    • Fever

    • Chills

    • Headache

    • Vomiting

    • Altered sensorium

  • In Infants:

    • Hypo or hyperthermia

    • Poor feeding

    • Vomiting

    • Irritability

    • Restlessness

    • Seizures

    • Bulging fontanel

Complications

  • Include hydrocephalus, brain abscess, and increased ICP.

Diagnosis

  • Lumbar Puncture: Definitive diagnostic test for bacterial meningitis.

Transmission

  • Spread via droplet infections from nasopharyngeal secretions and as an extension from other bacterial infections through vascular dissemination.

  • Increased risk correlates with the number of contacts and seasonal variations (late winter and early spring).

Therapeutic Management

  • Diagnostics: Lumbar puncture is essential.

  • Management:

    • Isolation precautions.

    • Antimicrobial therapy.

    • Maintain hydration and ventilation.

    • Reduce increased ICP.

    • Manage shocks, seizures, and body temperature.

Drugs Used

  • Include empirical therapy, dexamethasone, and antibiotics.

Prognosis

  • Dependent on the organism and promptness of treatment; generally, sequelae may occur.

Nonbacterial Meningitis (Aseptic Meningitis)

Definition and Diagnosis

  • Caused primarily by viruses (e.g., arbovirus, herpes simplex virus, cytomegalovirus, HIV, and adenovirus).

  • Diagnosis relies on CSF findings.

  • Onset can be abrupt or gradual, with symptoms including:

    • Headache

    • Fever

    • Malaise

Treatment

  • Primarily symptomatic treatment.

Tuberculosis Meningitis

  • Considered for children who have traveled to developing countries.

  • Early Diagnosis is Key:

    • Manifestations include fever, altered LOC, seizures, and neurological deficits.

    • Complications potentially lead to hydrocephalus.

Nursing Care

  • Focus on support, medication administration, and pain control monitoring.

Brain Abscess

Definition and Causes

  • Forms when pyogenic organisms gain access to neural tissue.

  • Predisposing Factors:

    • Chronic ear infections

    • Mastoiditis

    • Sinusitis

    • Congenital heart disease

  • The common cause is streptococci.

Early Signs

  • Include vague, severe headache.

Signs of Progression

  • Progresses to:

    • Vomiting

    • Lethargy

    • Fever

    • Seizures

    • Papilledema

    • Hemiparesis

    • Coma.

Treatment

  • Surgical drain and antibiotic therapy as needed.

Encephalitis

Definition

  • An inflammatory process of the CNS with altered brain and spinal cord functions.

  • Various viral causes (the most involved being direct invasion by a virus), and vector reservoirs in the U.S. primarily include mosquitoes and ticks.

Clinical Manifestations

  • Common symptoms include:

    • Malaise

    • Fever

    • Headache/dizziness

    • Stiff neck

    • Nausea/vomiting

    • Ataxia

    • Speech difficulties.

Severe Encephalitis Symptoms

  • High Fever, stupor, seizures, disorientation, spasticity, coma, ocular palsies, and paralysis may occur.

Diagnosis and Treatment

  • Diagnosis based on clinical findings and identification of the organism.

  • Therapeutic Management:

    • Hospitalization for observation.

    • Supportive treatment.

    • ICP monitoring may be required.

    • Follow-up care with reevaluation and rehabilitation.

    • Increased risk of neurologic disability in very young children.

Reye's Syndrome

Definition

  • A disorder defined as toxic encephalopathy associated with impaired liver function.

  • Characterized by:

    • Fever

    • Profoundly impaired consciousness

    • Disordered hepatic function.

Causes

  • Not well understood, typically follows common viral illnesses like influenza or varicella.

  • There may be a potential association between aspirin use and the development of Reye's syndrome.

Diagnosis and Prognosis

  • Liver Biopsy: Necessary for diagnosis.

  • Therapeutic Management: Early diagnosis and aggressive therapy improve prognosis.

  • Recovery seems good considering the severity of the disease.

Seizure Disorders

Definition and Overview

  • Seizures result from excessive and disorderly neuronal discharges in the brain and are determined by their site of origin.

  • They are the most common neurologic dysfunction in children and are often symptomatic of an underlying disease process.

Epilepsy

  • Defined as two or more unprovoked seizures caused by various pathologic processes within the brain.

  • Optimal treatment and prognosis rely on an accurate diagnosis and the determination of the underlying cause.

Causes of Seizures

  • Acute Symptomatic: From acute events like head trauma or meningitis.

  • Remote Symptomatic: Due to prior brain injury such as encephalitis or stroke.

  • Cryptogenic: No clear cause identified.

  • Idiopathic: Genetic origin suspected.

Seizure Classification

Types

  1. Partial: Localized onset involving a small area of the brain.

  2. Generalized: Involves both hemispheres without local onset.

  3. Unclassified: Not fitting into the other classifications.

Therapeutic Management of Seizure Disorders

  • Goals include controlling seizures and reducing frequency/severity.

  • Key management strategies are:

    • Drug therapy.

    • Ketogenic diet.

    • Vagus nerve stimulation.

    • Surgical therapy.

Status Epilepticus

  • A medical emergency requiring immediate intervention to prevent brain damage.

  • Prognosis depends on timely treatment and underlying conditions.

Long-Term Care

  • Aimed at achieving the goal of living as normal a life as possible despite the disorder.

Febrile Seizures

Overview

  • Definition: A transient disorder of childhood, affecting approximately 2 ext{%} to 5 ext{%} of children, typically occurring between 6 months and 3 years of age. Rarely seen after age 5.

  • Frequency: Twice as common in boys.

  • Cause: Uncertain; often associated with viral infections.

Hydrocephalus

Definition

  • Hydrocephalus results from an imbalance in the production and absorption of CSF.

  • Pathophysiology:

    • Impaired absorption of CSF within the subarachnoid space.

    • Obstruction within the ventricular system.

    • Can be categorized into communicating and noncommunicating hydrocephalus.

Causes of Hydrocephalus

  • Usually appears due to developmental defects, evident in early infancy.

  • Other causes may include neoplasms, infections, and trauma; often associated with myelomeningocele.

Therapeutic Management of Hydrocephalus

  • Aimed at relief of hydrocephalus and treatment of complications regarding motor development effects.

  • Most Common Treatment: Surgeries (ventriculoperitoneal shunt).

  • Shunt Infections: Present a significant risk during the period of 1 - 2 months after placement, which can lead to septicemia, bacterial endocarditis, wound infections, shunt nephritis, or meningitis.

  • Treatment of Infections: May involve massive-dose antibiotics or shunt removal.