Imbalance in the Production & Or Absorption of CSF in the Ventricular System
- Brain strikes parts of the skull
- Coup is the point of impact
- contrecoup is the point of impact opposite the initial
injury
- Other problems
- Shearing stresses: injury to the brain from sliding
against inside the skull
- Compression
CONCUSSION
- A traumatically induced alteration in mental status
- Transient and reversible
- Hallmarks: * Confusion, Amnesia
- Mild to moderate concussion with/without loss of
consciousness
- Will be allowed to go home
CONTUSION
- Bruising of cerebral tissue
- Frequently the result of coup and or coutrecoup
- disturbances in strength, sensation, or vision
LACERATION
- Tearing of cerebral tissue
- Frequently associated with a skull fracture
- More severe than a contusion
LINEAR FRACTURE
-Through entire thickness of bone
- Uncommon before 2-3 years of age b/c bones are more
pliable
- Most are associated with overlying hematoma or soft
tissue swelling
DEPRESSED FRACTURE
- Bone is broken, usually into several fragments that are
pushed inward
- uncommon before 2-3 years of age
BASILAR FRACTURE
- Basilar portion of the frontal, ethomid, sphenoid,
temporal, or occipital bones
- Posttraumatic meningitis should be suspected in children
who develop either increasing drowsiness and fever who
have a basilar skull fracture
-*** Never insert an NGT into a pt with a basilar skull fx
b/c you could easily thread it though to brain
EPIDURAL HEMORRHAGE
PATHO
- Blood accumulates rapidly (typically from an artery) b/w
the dura and skull
- Hematoma
- Forces brain tissue downward and inward
- Lower incidence in children
- middle meningeal artery is not embedded in surface of
skull until 2 years old
CLASSIC SIGNS
- Momentary unconsciousness
- Normal period
- Lethargy or coma
- Classic signs seldom evident in children
- Frequently no unconscious period
- “normal period” frequently not asymptomatic
- irritable, HA, vomiting
SUBDURAL HEMORRHAGE
PATHO
- Bleeding between the dura and cerebrum as a result of
venous injury (usually the cortical veins)
- Spreads slowly through the dural space
- More frequent than epidural hemorrhage
- Children with a subdural hematoma and retinal hemorrhages should be evaluated for the possibility of child abuse, especially shaken baby syndrome
TREATMENT
- Repeated subdural taps in infants to remove excess fluid
- If fontanels still open a needle can be inserted there to
drain fluid
- Surgical evacuation of hemtoma in older children
ICPPATHO
1. Cerebral edema
2. vascular stasis
3. Anoxia
4. Further vasodilation
5. When ICP exceed arterial pressure
- Fatal anoxia or herniation
- The cranium’s volume must remain approximately the
same at all times
- Limited compensatory ability
- Reduction in blood volume in brain, which results
in anoxic injury
- decrease in CSF production
- Shrinkage of brain mass
- Open fontanels and widened sutures
SIGNS/SYMPTOMS
- Early signs may be subtle: irritable, restless, sleepy
- Classic S/S: HA/vomiting
- Infant
- Tense and or bulging fontanel (check when baby is
sitting up
-***High pitched cry
- Separated cranial sutures
- Setting sun sign: kid is looking down all the time, the
whites of the eyes are seen above the iris
HEAD INJURY: INITIAL ASSESSMENT
-ABC: airway with cervical spine immobilized
- Glasgow coma scale: tool used to eval LOC
- Eyes, Ears, Nose, Mouth
- check for bleeding
- test clear drainage for glucose
- PAIN: no analgesics or sedatives
- SKIN: scalp lacerations (bleed disproportionally to injury)
COMA SCALES
- Quick, practical, standardized system for assessing the
LOC impairment
- Assessing LOC impairment in infants and very young
children is problematic
- Pediatric coma scales generally include a section for
those less than 2 yrs old
PEDIATRIC GLASGOW COMA SCALE
- Three part assessment
- eye opening
- verbal response
- motor response
- Each response is rated on 1-5 scale
- highest score: 15
- score of 8 or less: coma
- Lowest score of 3: deep coma
EYE OPENING
4. child opens eyes spontaneously when you approach
3. child opens eyes in response to speech
2. Child opens eyes only in response to painful stimuli
1. Child does not open eyes in response to painful stimuli
**if possible, ask parent to approach child b/c they may
keep eyes closed out of fear of hospital staff
** If kids eyes are fixed and dilated, it’s a sign the child is
herniating. EMERGENCY
- 2 year old could be able to tell you their name
DECORTICATE POSTURING
- Dysfunction of cerebral cortex
- Adduction of arms at the shoulders
- Flexion of arms on the chest
- Wrists flexed and hands fisted
- Extension and adduction of legs
DECEREBRATE POSTURING
- Dysfunction at midbrain
- Rigid extension and pronation of the arms and legs
- This is the worse of the two
MOTOR RESPONSE
- Posturing may not be seen when child is quiet or propped
with pillows/blankets, etc. May be elicited by painful
stimuli
- Lack of response to painful stimuli is abnormal and
should be reported immediately
INTRACRANIAL INFECTIONS
BACTERIAL MENINGITIS
ASEPTIC MENINGITIS
ENCEPHALITIS
BACTERIAL MENINGITIS
Inflammation of the meninges covering the brain
- Can lead to significant residual damage
- hydrocephalus
- hearing loss
- loss of limbs
- destruction of brain tissue
- Majority of cases are 1 month to 5 yrs old
PATHO
1. bacteria cross the BBB
2. bspreads into CSF and subarachnoid space
3. Brain swells
4. brain surface is covered with purulent exudate
5. infection spreads to ventricles
6. Pus may obstruct narrow passages
7. obstruction of CSF flow
- frequent bacteria is present from an infection at another part of the body: otitis media, etc.
MENINGITIS & CSF
- Fluid pressure is measured
- Culture and gram stain
- Blood cell count: WBC- elevated neutrophils, occasionally
presence of RBCs in spinal fluid, usually r/t bloody tapcc
(needle punctured capillary and blood leaked into spinal
fluid)
- Glucose decreased
- Protein increased
SPINAL TAP (LUMBAR PUNCTURE)
-EMLA at L3-L5 at least 1 hr before procedure
- Draw an imaginary line from top of iliac crest across
the spine to top of iliac crest (L4)
** The diagnostic test for meningitis
- Position kid close to edge of table
- place on side, head flexed, knees toward chest
- Immobilize child’s spine in flexed position
- enlarges spaces b/w lumbar vertebra spines
** Watch kid’s respirations b/c you can occlude their airway if you flex them too much. Put on pulse ox
ALTERNATE POSITION
- Butt at edge of table
- Neck flexed and arm resting of chest on nurse’s arm
- Arms and legs immobilized
- Crying good b/c CSF will come out quicker.
S/s MENINGITIS
INFANT AND YOUNG CHILD
- Fever
- Poor feeding
- Vomiting
- Seizures:maybe
- High pitched cry
- Bulging fontanel
* Opisthotonos: hyperextension of head and neck which
relieves discomfort for them
CHILD AND ADOLESCENT
- Fever
- HA
- Vomiting
- Seizures
- Positive Kernig & Brudzinski sign
- Nuchal Rigidity
- May progress to Opisthotonos
KERNIG SIGN
1. Child supine
2. Flex knee
3. Extend leg at knee
4. Resistance or pain???
BRUDZINSKI SIGN
1. flex head while in supine position
2. Knees or hips flex involuntarily???
MENINGOCOCCAL MENINGITIS
- Petechial or Purpuric Rash
- Contagious
- Immunization: given around age 10, not required, but
recommended for those who are in close living quarters
with others (such as college students)
BACTERIAL MENINGITIS: INVERVENTIONS
- Isolation until proven noncontagious
- Antibiotics: IV immediately
- Maintenance fluids or less
- Correct fluid deficit
- Keep in mind cerebral edema. Don’t want to put them
into fluid overload
- NPO with dulled sensorium
- Quiet environment: kid irritated by sounds and lights
- Elevate HOB: generally kid will lay on side due to nuchal
rigidity. Pillows may be uncomfortable
- Head circumference to monitor for
- Subdural effusions
- Hydocephalus
BACTERIAL MENINGITIS COMPLICATIONS
- Cerebral edema
- Subdural effusion
- DIC: clotting system inappropriately activated, child starts
bleeding a lot, then clotting. Those clots block stuff, leads
to necrosis
- Shock
- Hydrocephalus
BACTERIAL MENINGITIS: FOLLOW UP
- Neurological exams
- convalescent period
- regular intervals for a year after the disease
- Evaluation of CN VIII for at least 6 months after disease
- Vestibulocochlear: potential damage to hearing due to
ototoxic abx, could cause loss of hearing
ASEPTIC MENINGITIS (NONBACTERIAL)
CAUSED by viruses
- frequently associated with other diseases
- measles (see breakouts), mumps (don’t see much),
Enteroviruses (commonly seen)
- Treat principal infection
S/S
- HA, FEVER
- GI symptoms: ABD PAIN, N/V
- Signs of meningeal irritation: sensitivity to light and
sound, HA, irritability
ASSESSMENT
- Muscle aches and pains?
- give Tylenol
- Lumbar puncture/spinal tap: CSF shows increased
lymphocytes in viral. (increased neutrophil indicated
infection)
- S/S usually subside rapidly
- well in 3-10 days. Usually no residual effect
ENCEPHALITIS
- Enterovirus
- Arthropod Vector (mosquito/ticks)
- Post infection autoimmune response
- Direct invasion of CNS by virus
PATHO
1. widespread nerve degeneration in the brain
2. Edema
3. Areas of necrosis with or without hemorrhage
4. Increased ICP
5. Herniation possible
Continuum is from mild to severe
1. malaise
2. fever----HA---Neck stiffness---ataxia
3. (severe) Paralysis---coma
SEIZURES
TYPES OF SEIZURES- Provoked seizure: something triggered it
-Febrile seizure
- Systemic condition: hypoglycemia, hypoxia, meningitis
- following an injury to the CNS: MVA with head injury
- Unprovoked (idiopathic) seizure
- no identifiable cause
FEBRILE SEIZURES
- Age 6 mo to 3 years, possibly even up to 5 yrs but rare
after age 5
- usually occurs in those younger than 18 months
- Degree of temperature is a factor
- Occurs while the temperature is rising
- Temperature usually greater than 101.8
- Generally seizure has stopped before arriving at the ER
- Provoked, tends to be familial
TEACHING
- 95% of children with febrile seizures will not develop
epiliepsy or any neurological damage
- Teach parents
-How to protect child from harm: turn them on their
side, NPO, don’t try to stop seizure, don’t rush to the
ER, but stay with child and wait for ambulance
- To observe EXACTLY what is happening
- Tepid sponge baths are NOT effective: uncomfortable
and cause crying… ^BMR, ^Temp
- If seizure lasts longer than 5 mins, call 911
PARTIAL SEIZURE
- symptoms are r/t the area of vertebral involvement:
usually the cerebral cortex
- involve one area of the brain
CHARACTERIZED AS:
- Simple Partial
- Complex Partial
- Secondarily Generalized
SIMPLE PARTIAL SEIZURE
- Called simple b/c they don’t involved altered consciousness but pt can control symptoms? Tend to have
no aura
Simple Partial Seizures cont…
-Motor Symptoms
- Usually involve one side of body (one extremity, one
part of an extremity, or one whole side)
- Sensory Symptoms
- Numbness, tingling, humming or buzzing sound, flash
of light or color seen
- Autonomic Symptoms
- pupils dilate, Epigastric rising (stomach moving to
throat)
COMPLEX PARTIAL SEIZURES
- Complex b/c they involve altered consciousness
- Aura frequently occurs
- Automatisms
- repetitive, non-purposeful, involuntary activity
(lip smacking, patting themselves, rubbing, walk or run
unknowingly, touching themselves unkowningly)
- Motor Symptoms
- same as simple partial
- Psychic Symptoms
- same as simple partial
SECONDARY GENERALIZED SEIZURES
- Begins in one area of the brain and spreads to include
both hemispheres during the seizure itself, making it
generalized seizure
- The difference b/w this type and a generalized is that
a generalized seizure
- does not have a focal starting point
- involves both sides of the brain from the beginning
GENERALIZED SEIZURES
- Involves both hemispheres of the brain from the very
beginning
- TYPES OF GENERALIZED SEIZURES
- Tonic-clonic- “grand mal”
- Absence seizure- “petit mal”
- Atonic and akinetic seizure “drop attacks”
- Myoclonic seizures
- Infantile spams
TONIC-CLONIC SEIZURE
- Abrupt onset
- usually has an aura
TONIC PHASE
- Eyes usually roll upward (like the undertaker)
- Loss of consciousness
- Stiff an rigid as a result of muscle contraction
- arms flexed
- legs, head, neck extended
- mouth snaps shut
- Tonic cry
- Apnea
CLONIC PHASE
- Jerking movement as the body undergoes contraction
and relaxation
- Drooling or foaming at the mouth
- Incontinence
POSTICTAL PHASE
ABSENCE SEIZURE (PETIT MAL)
- Sudden onset
- Brief loss of consciousness
- Blank stare: don’t know what happened during this time
- Slight loss of muscle tone
- may drop object, but won’t fall down
- Amnesia for Episode
- Multiple episodes during day :20-100
- Interferes with school work: teachers/parents
frequently think the problem is daydreaming or not
paying attention
ATONIC SEIZURE (DROP ATTACK)
- Momentary loss of consciousness
- Mild case: sudden, brief head drop
- More severe: suddenly falls to ground, child cannot break
fall. **May need a helmet or face guard
- Quickly regains consciousness
MYOCLONIC SEIZURE
- No loss of consciousness: recovers in seconds
- Occur most often falling asleep or awakening but can
occur at any other time
- Quick involuntary muscle jerks
INFANTILE SPASMS
- Sudden, brief, symmetric, muscular contractions that
occur in clusters: 5-150/day
- Head flexed, arms extended, legs drawn up
- Eyes sometimes roll upward or inward
- May have altered consciousness
- Over time, seizure activity increases in severity
- Regression of development milestones
SEIZURE: ASSESSMENT
HISTORY
- Prenatal, perinatal, postnatal,
- family
DESCRIPTION OF SEIZURE
- Reliable seizure informant
- Description of behavior during seizure
- Postictal feelings and behavior
- Factors that may have precipitated seizure
- CBC & serum electrolytes
- Lumbar puncture (maybe)
- EEG: definitely will do this. Measures electric activity of
cerebral cortex
- Split-screen EEG: recording brain waves and recording
behavior (video) at the same time to study correlations
- CT and or MRI
- Some pts can be having a seizure and you can’t tell. They still function well, drive, talk to you
SEIZURES: DOCUMENTATION
- Describe
- what you saw: eyes rolled back/ deviated… etc
- Aura? Ask pt after they recovered
- Postictal period
- What you did to help the pt: positioning? Meds?
- The patient’s response
- Time the seizure
- Describe safety precautions
SEIZURES: SAFETY
- Stay with child
- Isolate from view if possible
- If standing or sitting, ease to floor
- Position on side
- Position on side
- O2 and oral suction (no deep suction), PRN
SEIZURES: SAFTEY cont…
- don’t force anything into mouth
- do not try to forcibly stop seizure
SEIZURE PRECAUTIONS IN THE HOSPITAL
- padded side rails
- O2 setup
- Functioning flow meter
- extension tubing
- mask or other type of delivery device
- Suction setup
- Functioning suction unit
- Extension tubing
- Yankuer or other type of catheter
DRIVER’S LICENSE
- Seizure free for 6 months to obtain
- Under a Physician’s Care to Assess
- Control of anticonvulsant medication
- Medication side effects
- Neuro or medical changes in condition: not getting
worse or having breakthrough seizures
- Statement from Physician
- Reliable in taking medications
- avoids sleep deprivation
- avoids alcohol use
ANTICONVULSANT MEDICATION
- Tablet form is preferred
- child may not receive adequate dose from liquid
preparation- or may receive too much (they are
suspensions and have to be shaken appropriately)
- Rectal administration when unable to take medications:
in status epilepticus or having a seizure
SPECIFIC MEDICATIONS
- Generalized seizures:
- carbamazepine (Tegretol)
- phenytoin (Dilantin)
- fosphenytoin (Cerebyx)
- valproic acid (Depakote or Depakene)
- Others
- gabapentin (Neurontin
- lamotrigine (Lamictal)
VAGUS NERVE STIMULATOR
- Implanted under skin: wire connects to vagus nerve in
neck
- Weak electrical impulses along the vagus nerve help
prevent seizures: specifically partial seizures
- Turn On/Off with magnet: swipe across the device to
help stop a seizure
STAUS EPILEPTICUS
- Continuous seizure
that lasts more than 30 mins
- A series of seizures where the child does not have time to
recover from each seizure
- Diazepam (valium)
- Lorazepam (Ativan- usually given in pedi)
- Fosphenytoin
Imbalance in the production & or absorption of CSF in the Ventricular System
HYDROCEPHALUS- Often congenital
- overall incidence is 1 per 2000 births
- commonly associated with myelomeningocele
- Complication of illness
- Meningitis
- Brain tumor
- A complication of injury
- Intraventricular hemorrhage
- Brain injury
PATHO
- CSF is produced by the choroid plexus within the lateral 3rd and 4th ventricles
- Rate of production is about the same rate as rate of absorption
- absorbed by the subarachnoid space into the venous
circulation
1. Imbalance between secretion and absorption of CSF
2. Increased accumulation of CSF in ventricles
3. Ventricles dilate
4. Compression of brain tissue against skull
* Results in damage to brain tissue; ventricles are the four hole looking things in the center of the brain
TYPES
- Communicating Hydrocephalus: most common
- impaired absorption of CSF within the subarachnoid
space
- Ventricles communicate: the normal flow of CSF thru
all ventricles is still there
- Non communicating Hydrocephalus
- Obstruction to the flow of CSF within the ventricles,
such as brain tumor
- Ventricles do not communicate
CHILD WITH AN OPEN FONTANEL
- Rapidly increasing head circumference
- Tense, Full, Bulging fontanel
- Progressive neurological signs
- Irritability or lethargy
- Poor feeding
- Decline in level of consciousness
- Shrill, high pitched vomiting
- Vomiting
A CLOSED FONTANEL AND SUTURES
- Many times a result of
- infection, tumor, hemorrhage
- Progressive neurologica signs
- HA upon awakening
- Irritability, lethargy, poor appetite
- personality change, loss of interest in daily activites
- Alteration in motor skills
TREATMENT
- Surgical Correction
- Remove obstruction (if present)
- Placement of Shunt: ventriculoperioneal
- Revision of shunt may be needed
- infection, damage to shunt mechanism, growth
VENTRICULOPERITONEAL SHUNT
- Drains CSF from ventricles to another site
- usually in the peritoneal cavity
- Right atrium (ventriculoatrial shunt): only if you can’t
put it in peritoneum due to scarring or something but
puts extra workload on the heart
- Pleural spaces
- Valves open at a predetermined intraventriuclar pressure
& close when the pressure falls below that level
- Has a present pressure limit: when CSF reaches that
pressure, it begins to drain excess fluid into peritoneal
cavity
*Post-Op: check incisions on scalp, behind ear, and on ABD
COMPLICATIONS
- Mechanical difficulty: kinking, plugging, separation,
migration of tubing
- Most often mechanical obstruction
- Particulate matter: pus
- Thrombosis
- Displacement as a result of growth: surgeon puts in
extra tubing length to allow for growth
- Shunt infection
- greatest risk 1-2 months after placement
- Of greatest concern meningitis & ventriculitis
VP SHUNT COMPLICATIONS cont…
- Massive doses of ABX
- Persistent infection
- Removal of shunt, massive doses of ABX
- Placement of external ventricular drain: CSF drained
into bag hung at side of the bed, ear has to be level
with “0” reference on pole holding bag, child has to lay
flat on bed at specific angle for at least a week
POSTOPERATIVE CARE
- Is shunt working?
- Head circumference: larger?
- Signs of increasing ICP:
- HA, Photophobia, Nuchal rigidity
- Surgical site:
- drainage, infection
- redness, swelling of shunt tract
DISCHARGE TEACHING: LIFELONG TREATMENT
- Notify health care provider immediately
- signs of shunt failure: sings of increased ICP, changes
in motor skills/school work.
- signs of infection
- seizures
- Infants with large head and poor head control should not
be placed in forward facing car seats regardless of age
- Appropriate referrals: wide range of impairment
NEUROMUSCULAR DISEASES