Neurocerebral Rounds 1:
The nervous system consists of the brain, spinal cord and nerves.
Neurological alterations can occur in children due to structural defects, infectious processes, or injury. These may be congenital or acquired.

Remember the 80/10/10 Rule: the cranium's volume is 80% brain tissue, 10% CSF and 10% blood.

CSF:
500 ml produced/day, 100-160 ml circulating at any one time.
Circulates within the ventricles in the brain.

Provides:
Buoyancy - Brain is 1400grams reduced to 50 grams
Protection - Cushion
Chemical stability - chemical, endocrine transports hormones
Prevention of ischemia
Clears wastes - one way flow

CSF article


If this delicate balance is not maintained problems occur.
Children with fontanels and sutures can compensate to a degree, this swelling results in hydrocephalus.
In older childern (after age 12) sutures are fused and will not open so compensation of this nature cannot occur.

Diagnostics often used to detect pathology include:
Computed axial tomography (CT)
Magnetic Resonance Imagery (MRI)
Electroencephalogram (EEG)

General Nursing Issues:
*Always start with ABCD's*
A = Airway
B = Breathing
C = Circulation
D = Disability or neurological status

Once ABCD's are taken care of, neurological assessment continues:
Level of consciousness - AVPU or Glasgow Coma Scale
Motor responses - strength, symmetry
Sensory evaluation - responses to temperature (hot vs.cold), pressure (mild, mod. severe), pain (sharp vs. dull), Proprioception (awareness of postion, movement)
Reflexes - presence, absence, symmetry, Babinski, biceps, triceps, patellar, ankle, and cranial nerves
Physical abilities compromised, sequelae, contractures, muscle atrophy, skin breakdown

AVPU -
A = Alert and awake
V = Responsive to verbal stimuli
P = Responsive to painful stimuli
U = Unresponsive

Seizures:
Caused by uncontrolled electrical activity in the brain
Can be partial, generalized or unclassified
Simple or complex

Causes:
Fevers
Infections
Cardiac anomolies
Trauma
Hypoxia
Breath holding spells
Gastroesophageal reflux
Epilepsy
Genetic factor
Idiopathic causes

Infant seizures can be due to congenital defect, birth injury, endocrine dysfunction, CNS infection, hypoglycemia
Older children trauma or infection, changes in diet, hydration status

Febrile seizures
Brief, clonic, tonic/clonic, simple or complex
Usually develop after a high fever but can be as low as 100 F
Simple - <15 min., few seconds, don't recur in 24 hours
Complex - >15 min., focal attributes, can reoccur on the same day
Rarely occur before 9 months or after 5 years

Unprovoked first seizure
without cause
<50% will have a second
Family history, developmental history, labs,

Epileptic seizures:
Presence of more than one unprovoked seizure
Childhood epilepsy may be a sign of CNS immaturity
More than 1/3 will be off medication and no longer have seizures by 23 years
Poorer prognosis if develop in infancy or adolescence, difficulty in management, cerebral palsy

Pathophysiology:
Electrical discharge of hyperexcited brain cells in epileptogenic focus
triggered by environmental or physiological stimuli (emotional stress, anxiety, fatigue, infection, metabolic diff)
Small area of brain = focal seizure

Status epilepticus = prolonged or a series of convulsions which occurs for a prolonged period and does not allow the child to regain consciousness before another begins. This is an emergency which can cause exhaustion, respiratory failure and death.
Refractory seizures last for more than 60 minutes

Clinical manifestations:
Simple Partial
small area of brain
Starts at any age and can have a variable number of seizures a day
Last <30 seconds, with no loss of consciousness, no automatisms, and no postictal impairment or confusion
localized motor symptoms
Somatosensory, psychic, autonomic symptoms
Aura, may be the sole manifestation
movements may involve one extremity
abnormal brain discharges unilateral
Aversive seizure - turn away from the side of focus
Rolandic (Sylvan) tonic-clonic involving face and mouth during sleep
Jacksonian march or Jacksonian seizure, rare in children
Simple partial with sensory signs may include parathesia, numbness, tingling, visual sensations or images, motor phenomena




Complex partial seizures
Usually in children over 3
period of altered behavior with no recollection of the event
Inability to respond to the environment
Impaired consciousness
Postictal impairment and mental disorientation, Drowsiness, confused
Rarely more than 2 a day, usually >60 seconds
Aura, deja vu, abdominal pain, taste, odor, visual changes
Stops activity and begins staring or nonpurposeful actions (automatisms)

Generalized
Diffuse electrical activity, involve both hemispheres of the brain
Always lose consciousness
No aura but prodrome of vague symptoms
Under age 4 associated with developmental delays, learning disabilities,
Uncontrolled motor involvement with movements and spasms, bilateral and symmetrical

*4 types - tonic/clonic, myoclonic, absence or akinetic

Tonic/Clonic (formally known as grand mal) Tonic phase 10-20 seconds, clonic 30 seconds but can last to a half an hour, occur without warning, postictal state, no remembrance of event.



Myoclonic - may or may not lose consciousness, may or may not be symmetric, No postictal state, sudden brief contractures of a muscle or muscle group.

Akinetic - Drop attacks - onset between 2 and 5, sudden loss of muscle tone, momentary loss of consciousness, occurs frequently during the day especially in the am.

Absence seizures after age 3, usually multiple seizures lasting <10 seconds every day, No aura, loss of consciousness, frequent automatisms, occassional clonic movements, no postictal, no confusion



Seizure Care


Management:
Control of seizure activity is the goal of treatment.
Reduce the frequency and severity of the activity
Discover the cause
Assist the patient to live as normal a life as possible

This can be achieved by 4 means:
Drug therapy
Ketogenic diet (high fat, low carbohydrate) mimics fasting state, burning fats ketosis, stablilizes cell membranes
Vagus nerve stimulation
Epilepsy surgery



Nursing care management:
*Maintain the airway
*Minimize the risk for injury
*Observe the seizure episode and document the events*
Document only what is observed rather than try and label the activity
If standing or seated move to the floor
Place pillow or blanket under head
Move to the side to facilitate drainage
Clear area of dangerous objects
do not restrain
If vomiting occurs turn head to side
Minimize the risk for aspiration
Maintain tissue perfusion
Teaching to minimize fear and coping disturbances

Trigger identification and education
lack of sleep, fatigue, stress
changes in temperature
sudden loud noises, sudden movements
illness, hypoglycemia, low protein diet
lights, reflections, camera flash
caffiene
hyperventilation
Assist parents with education
Medication administration, pill preferred, behavioral changes possible
Rectal meds available if vomiting
Involve teachers
Reassure parents about intelligence, future, stigma
Child needs involvement in care also

FYI
Children receiving phenobarbital or phenytoin (Dilantin) should be sure and receive adequate vitamin D and folic acid. However, phenytoin should not be taken with milk.

Phenobarbital has a sedative effect and is usually used in combination with other medications.

Dilantin (Phenytoin) is often the drug of choice. It can cause gingival hyperplasia. IV it is incompatible with glucose so flush IV line before and after administration.

Diazepam is incompatible with many drugs, give slowly IV directly into the vein or close to the vein insertion site.

Fosphenytoin is sometimes used IV instead of phenytoin (Dilantin) because of the number of drug interactions.

*If Dilantin (Phenytoin) is given IV, it is given slowly at a rate of 50mg/minute.

Safety considerations:
Showers preferred
Siderails padded
Waterproof matress pad
Never swim alone
Wear helmets during skating, biking
Medical alert ID
Child may not drive or operate machinery unless seizure free for a specified amount of time determined state to state.

*Call 911 if:
child stops breathing
first seizure
seizure in water
child is unresponsive after
child vomits continuously for 30 minutes after
pupils are not equal
evidence of injury

Seizure surgery


Case study:
The nurse is working in a local pediatric evening clinic. She is alone except for the attending physician, resident, translator and secretary. As she is rooming patients, she hears a scream and a woman runs to her with an unconscious child. The woman is screaming hysterically "fiebre, fiebre...". The nurse notes that the child is unconscious, has some perioral cyanosis and is drooling. What is the first course of action? What needs to happen next? Sequence out the care of this child. Include all aspects including teaching.

Neurocerebral:
Infections of the neurological system:


Meningitis - Bacterial and viral

Infection affecting the meninges caused by bacteria such as meningococci, pneumococci, and Haemophilus, viral agents or tuberculosis.

Bacterial Meningitis is an infection of the meninges and the CSF.
The Haemophilus vaccine (Act-Hib, Pedvax) and the pneumococcal (Prevnar, PCV 13) have decreased bacterial cases.
These two bacteria along with Neisseria meningitis (meningococcus) cause 95% of cases older than 2 months of age.
The meningococcal vaccine (Menactra) is available for ages 11-55 years old.

Incidence
1 month and 5 years bacterial
school age and adolescents - meningococcal

Pathophysiology
This infection generally comes from vascular dissemination from another foci of infection.
Less frequently from the mastoid or paranasal sinuses.
As in any infectious process exudate (pus) covers the brain and can clog the flow of CSF.

Diagnosis:
Diagnosis is made by a lumbar puncture.
Examination of CSF reveals elevated WBCs and protein, while glucose is reduced
Blood cultures
Nose and throat cultures.
Ct scan

Signs and symptoms:
Onset may mimic the flu and occur over a couple of days or it may be abrupt.
fever
headache
chills
seizures
irritability
agitation
vomiting
Photophobia
nuchal rigidity
delirium, stupor and coma may also occur.

Infants and young children have less specific signs and symptoms. Poor feeding, a bulging fontanel, irritability, vomiting and seizures may be more typical of infants. A petechial rash can indicate a fulminating course of meningococcemia. This is a medical emergency.

InterventionsOutcomes/Management includes:

Isolation
*Septic workup first*
Antimicrobial therapy: Cephalosporins are drug of choice
Hydration
Maintenance of ventilation
Reduction of increased ICP
Management of septic shock
Control of seizures
Control of temperature
Treatment of complications
Dexamethasone helps with increased ICP but is not advised for viral meningitis



*Complications include shock, disseminated intravascular coagulation syndrome (DIC), seizures, hearing loss, 10-15% fatal

Nursing care:

Septic workup:
Assist with lumbar puncture
Blood cultures, labs, IV, cath
Assessment: LOC, S&S increased ICP, vital signs (what might I see?), Respiratory distress, I&O, S&S shock, Pain

Pain control:
Medications
Positioning - No pillow, head of bed slight elevation, side lying often more comfortable

Comfort: few visitors, low lights, decrease noise and stimuli


*Aseptic or viral meningitis is self limiting, it must be differentiated from bacterial and care is supportive*





Viral Meningitis


Encephalitis

An inflammatory process of the CNS caused by any number of organisms such as bacteria, spirochetes, fungi, protozoa, helminths and viruses. More than half of reported cases have an unknown cause, however many are associated with the childhood diseases of measles, mumps, varicella and rubella. Enteroviruses, herpesviruses and the west nile have also been implicated.

Herpes simplex encephalitis is an uncommon disease but 30% of the cases that do occur happen in children. The early use of acyclovir has helped decrease mortality and morbidity.

Encephalitis often occurs in hot summer months due to mosquitos.

Signs and symptoms
similar regardless of the cause - initially flu-like symptoms, gradual or sudden
May be mild similar to a mild aseptic meningitis or to a severe case
malaise
fever
headache
dizziness
apathy
nuchal rigidity,
nausea, vomiting
ataxia
tremors
hyperactivity
speech difficulties
seizures, disorientation, spasticity, coma and death.

Nursing care is similar for the child with meningitis

Reye's Syndrome (RS)
defined as Toxic Encephalopathy.
It is poorly understood but tends to follow a viral illness such as the flu or chicken pox.

Characterized by cerebral edema and changes in the liver.
Link associated between viruses, aspirin, toxins, drugs, genetic factors



Signs and symptoms:
fever
severe hepatic dysfunction: liver complications
protracted vomiting: increased ICP
neurological impairment which includes personality changes and loss of consciousness (increased ICP)

Diagnosis:
Liver biopsy provides the definitive diagnosis.
It is staged I-V.
Elevated ammonia levels
Early diagnosis and therapy is vital.
Recovery can be rapid
1/3 of the cases end in severe impairment or death.

Nursing care:
Assist with lumbar puncture
Blood cultures, labs, IV
Check LOC, observe for increased ICP
Possible NG tube, catheter, endotracheal tube
Monitoring intake and output
Check coagulation since liver is affected
Parental teaching about aspirin...viral illnesses

Rabies: CDC rabies link
Viral - transmitted by bite, scratch, multiplies in muscles so doesn't create antibody/antigen response until its to late
88% from wild animals - racoons, skunks, foxes, bats
12% domestic animals mostly cats
Unusual behavior in any animal is suspect
Bite by any wild animal is considered exposed
Uncommon in humans
Incubation 1-3 months but can be as quick as 10 days and as long as 8 months
Only 10-15% of persons bitten develop disease but once symptoms - fatal
Long incubation allows time for tx

Signs and symptoms:
malaise
fever
sore throat
hypersensitivity
increased rx to external stimuli
seizures
maniacal behavior
choking
apnea
cyanosis
anoxia

Treatment:
*Capture animal, hold if domesticated for 10 days
*Cleanse wound
*Notify Health department

Antibiotics
Tetanus
Human rabies immune globulins
Human diploid cell rabies vaccine (HDCV)


Neurological Injuries:
Remember the cranium's volume is 80% brain tissue, 10% CSF and 10% blood.

Head trauma:
Concussion:
Most common head injury.
May not necessarily lose consciousness
Confusion and amnesia hallmark
Post concussion syndrome – last several days to several months, headaches, memory loss,
Second Impact Syndrome - returning to play before complete healing is dangerous!

Pathophysiologytearing of nerve fibers, release of acetylcholine and decreased amounts of oxygen

Care:
see head injury below




Contusion/laceration
Visible bruising, tearing of cerebral tissue
Petechial hemorrhages at the site – coup
Hemorrhages remote from the site – contrecoup
Infant’s brains are very pliable, so is the skull

Shaken Baby Syndrome –
profound neurological impairment, retinal hemorrhages, subarachnoid, subdural hemorrhages, unconsciousness, scarring, paralysis…

http://dontshake.org/

Shaken Baby



Fractures
Young children > skull flexibility
However may still tear an artery producing hypovolemic hypotension

Fracture types:
Linear fractures, Comminuted - multiple linear, Depressed fractures, Basilar - frontal, ethmoid, sphenoid, temporal, occipital, Open Diastatic

80% subcutaneous bleeding posterior neck area, raccoon eyes, hemotympanum bleeding behind tympanic membran, Battles sign

Complications:
Hemorrhage, edema, infection, herniation, compression
Rapidly fatal or slow and insidious

Epidural hemorrhage
Arterial brain compression occurs rapidly
Uncommon in children under 4

Subarachnoid hemorrhage:
Bleeding from torn veins during an accident, slow diffuse spread of blood into CSF, generalized pressure.

Subdural Hematoma:
Bleeding from torn bridge veins pours into area compressing brain.


Nursing Care for head injury: 80/10/10 Rule
Immediately Stabilize spine then:
ABC

Airway - jaw thrust
Bleeding – clean site, dress, ice
Circulation – vital signs, signs IICP opposite of shock
NPO > clear …
Assess pain but no analgesics,
PERRLA q4 x 48, what does this mean...
Check LOC - try to wake q 2 hrs
Hand grips, posturing
Manage pain, headache, seizures, nausea, vomiting,
Head of bed slightly elevated
Side rails up/padded
Quiet/low lights
No nasal suctioning, sterile cotton for ear/nose drainage
Antibiotics
Tetanus shot
Parental Teaching for home care
Family support
Rehabilitation


Seek Help!
Auto accident
Fall
Great force
Loss of consciousness
Amnesia
Crying > 10 min.
Headache that wakes from sleep
Bruising below eyes
Pupillary Changes
Neck pain
Unsteady gait
Blurred vision
Difficulty speaking
Confusion
Swelling infront of or above ear lobe
Vomiting > 3
Fluid draining from ear or nose (+ for dextrose CSF)
Bulging fontanelle
Vital sign changes IICP


Submersion - 80/10/10 Rule
Drowning and near drowning
Major problems:
Hypoxia - cells suffer irreversible damage after 4-6 minutes without oxygen
Aspiration - aspirated fluid causes spasms, infection, and edema
Hypothermia –
All children need to be hospitalized for at least 24 hours
Cerebral insult = degree of need
Sinus rhythum, normal PERRLA, normal neuro checks = best outcome
Family support
Family teaching





Brain Tumors**
Leukemia most common cancer in child but brain tumor is the most common solid tumors in children
60% infratentorial posterior 1/3
Supratentorial anterior 2/3
Benign or malignant

Signs and Symptoms: 80/10/10 Rule
No symptoms until begin to brain compression or CSF obstruction
Symptoms dependent on location
Headache on awaking
Vomiting
Neuromuscular changes
Behavioral changes
Cranial nerve neuropathy head tilt, visual changes
Vital sign changes
Seizures
Bulging fontanelle
Nuchal rigidity
MRI, CT, angiography, EEG diagnostic
Lumber puncture but must be careful

Treatment:
Surgery
Radiation
Chemotherapy water-soluble drugs can pass the blood brain barrier

Nursing care:
Assessment
Neuro checks PERRLA
Vital signs - hyperthermia,
History observe for behavior changes
Observe for seizures, vomiting
Reason for surgery, “To help with some of symptoms…”
Preparation pictures, save hair
Prepare parents for equipment
Observe dressing mark drainage, note color, consistency
No trendelenburg
NPO until swallow and gag return
Quiet, dim room

Neuroblastoma:
Most common malignant tumor in children
Originates from embryonic cells,
Silent, discovered 70% of time after metastasis
S&S depend upon the location of the tumor and extent of the disease.
Staged form I-IV
Neuroblastoma staging system 1-2 low risk excellent prognosis,
High risk staging with treatment 30-40% survival.
The younger child generally fairs better
Initial treatment focuses on work up and relieving the child's symptoms
Then chemotherapy and radiation








References:

Axton, S. E., & Fugate, T. (2003). Chapter nine: Care of children with neurological/neuromuscular dysfunction. In M. Connor & Y. Kopperman (Eds.), Pediatric nursing care plans (2nd ed., pp. 217-252). Upper Saddle River, New Jersey: Pearson Education.

Hockenberry, M. J. (2009). Chapter 28: The child with cerebral dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 974-1022). St. Louis, MO: Mosby Elsevier.

Videos:

Meningitis
https://youtu.be/URKtW21a9So
https://youtu.be/zQmQ5bz_IlY

Viral Meningitis
https://youtu.be/Ut_vXrDD2hU

Dangers of aspirin
http://youtu.be/vOKmQ14Vbho

Rabies

Videos:

How to recognize a concussion
http://youtu.be/wMlpP2dqfW0

Subarachnoid hemorrhage
http://youtu.be/GPVr_jG-v-s

Subdural hemorrhage
http://youtu.be/qO16QXMxBLY

Shaken Baby video
http://youtu.be/kgHRWH4USmw

Drowning
http://youtu.be/wnFzA3-ITj8

Neuroblastoma
https://youtu.be/0D_1urksPS4
References:
Axton, S. E., & Fugate, T. (2003). Chapter nine: Care of children with neurological/neuromuscular dysfunction. In M. Connor & Y. Kopperman (Eds.), Pediatric nursing care plans (2nd ed., pp. 217-252). Upper Saddle River, New Jersey: Pearson Education.

Hockenberry, M. J. (2009). Chapter 28: The child with cerebral dysfunction. In M. J. Hockenberry & D. Wilson (Eds.), Wong's essentials of pediatric nursing (8th ed., pp. 974-1022). St. Louis, MO: Mosby Elsevier.

Videos:

Dominic simple partial
http://youtu.be/gbryS0aIqOc

Bellasbattle tonic clonic seizure
http://youtu.be/SAo-UaE8YoY

ilovecodybug Akinetic seizure
http://youtu.be/A4G1BlyRbDM

mrturcious1 Absence seizures
http://youtu.be/H3iLQi6wt94

What to do in case of a seizure
http://youtu.be/xIQK1R4fhFw

Ketogenic diet
https://youtu.be/z4o-2j99a-c

Seizure surgery
http://youtu.be/2MKNsI5CWoU