Neurocerebral+Round+1

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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diagnostics often used to detect pathology include: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Computed axial tomography (CT) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Magnetic Resonance Imagery (MRI) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Electroencephalogram (EEG)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">General Nursing Issues: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">*Always start with ABCD's* <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">A = Airway <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">B = Breathing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">C = Circulation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">D = Disability or neurological status

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Once ABCD's are taken care of, neurological assessment continues: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Level of consciousness - AVPU or Glasgow Coma Scale <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Motor responses - strength, symmetry <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Sensory evaluation - responses to temperature (hot vs.cold), pressure (mild, mod. severe), pain (sharp vs. dull), Proprioception (awareness of postion, movement) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Reflexes - presence, absence, symmetry, Babinski, biceps, triceps, patellar, ankle, and cranial nerves <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Physical abilities compromised, sequelae, contractures, muscle atrophy, skin breakdown

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">AVPU - <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">A = Alert and awake <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">V = Responsive to verbal stimuli <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">P = Responsive to painful stimuli <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">U = Unresponsive

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Seizures: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Caused by uncontrolled electrical activity in the brain <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Can be partial, generalized or unclassified <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Simple or complex

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Causes: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Fevers <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Infections <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Cardiac anomolies <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Trauma <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Hypoxia <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Breath holding spells <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Gastroesophageal reflux <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Epilepsy <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Genetic factor <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Idiopathic causes

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Infant seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> can be due to congenital defect, birth injury, endocrine dysfunction, CNS infection, hypoglycemia <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Older children <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> trauma or infection, changes in diet, hydration status

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Febrile seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Brief, clonic, tonic/clonic, simple or complex <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Usually develop after a high fever but can be as low as 100 F <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Simple - <15 min., few seconds, don't recur in 24 hours <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Complex - >15 min., focal attributes, can reoccur on the same day <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rarely occur before 9 months or after 5 years

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Unprovoked first seizure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">without cause <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"><50% will have a second <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Family history, developmental history, labs,

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Epileptic seizures: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Presence of more than one unprovoked seizure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Childhood epilepsy may be a sign of CNS immaturity <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">More than 1/3 will be off medication and no longer have seizures by 23 years <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Poorer prognosis if develop in infancy or adolescence, difficulty in management, cerebral palsy

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Pathophysiology: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Electrical discharge of hyperexcited brain cells in epileptogenic focus <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">triggered by environmental or physiological stimuli (emotional stress, anxiety, fatigue, infection, metabolic diff) <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Small area of brain = focal seizure

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Status epilepticus <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">= 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. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Refractory seizures last for more than 60 minutes

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Clinical manifestations: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 170%;">Simple Partial <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">small area of brain <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Starts at any age and can have a variable number of seizures a day <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Last <30 seconds, with no loss of consciousness, no automatisms, and no postictal impairment or confusion <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">localized motor symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Somatosensory, psychic, autonomic symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Aura, may be the sole manifestation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">movements may involve one extremity <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">abnormal brain discharges unilateral <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Aversive seizure - turn away from the side of focus <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rolandic (Sylvan) tonic-clonic involving face and mouth during sleep <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Jacksonian march or Jacksonian seizure, rare in children <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Simple partial with sensory signs may include parathesia, numbness, tingling, visual sensations or images, motor phenomena

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Complex partial seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Usually in children over 3 <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">period of altered behavior with no recollection of the event <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Inability to respond to the environment <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Impaired consciousness <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Postictal impairment and mental disorientation, Drowsiness, confused <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rarely more than 2 a day, usually >60 seconds <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Aura, deja vu, abdominal pain, taste, odor, visual changes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Stops activity and begins staring or nonpurposeful actions (automatisms)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 160%;">Generalized <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diffuse electrical activity, involve both hemispheres of the brain <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Always lose consciousness <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">No aura but prodrome of vague symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Under age 4 associated with developmental delays, learning disabilities, <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Uncontrolled motor involvement with movements and spasms, bilateral and symmetrical

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">*4 types - tonic/clonic, myoclonic, absence or akinetic

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Tonic/Clonic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> (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.

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Myoclonic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> - may or may not lose consciousness, may or may not be symmetric, No postictal state, sudden brief contractures of a muscle or muscle group.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Akinetic <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">- 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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Absence seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;"> 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

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Seizure Care media type="youtube" key="xIQK1R4fhFw" width="560" height="315"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;"> Management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Control of seizure activity is the goal of treatment. <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Reduce the frequency and severity of the activity <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Discover the cause <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assist the patient to live as normal a life as possible

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">This can be achieved by 4 means: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Drug therapy <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Ketogenic diet (high fat, low carbohydrate) mimics fasting state, burning fats ketosis, stablilizes cell membranes <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Vagus nerve stimulation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Epilepsy surgery

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 150%;">Nursing care management: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Maintain the airway <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Minimize the risk for injury <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Observe the seizure episode and document the events* <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Document only what is observed rather than try and label the activity <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">If standing or seated move to the floor <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Place pillow or blanket under head <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Move to the side to facilitate drainage <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Clear area of dangerous objects <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">do not restrain <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">If vomiting occurs turn head to side <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Minimize the risk for aspiration <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Maintain tissue perfusion <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Teaching to minimize fear and coping disturbances

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Trigger identification and education <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">lack of sleep, fatigue, stress <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">changes in temperature <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">sudden loud noises, sudden movements <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">illness, hypoglycemia, low protein diet <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">lights, reflections, camera flash <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">caffiene <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">hyperventilation <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Assist parents with education <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medication administration, pill preferred, behavioral changes possible <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Rectal meds available if vomiting <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Involve teachers <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Reassure parents about intelligence, future, stigma <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Child needs involvement in care also

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">FYI <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Phenobarbital has a sedative effect and is usually used in combination with other medications.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Diazepam is incompatible with many drugs, give slowly IV directly into the vein or close to the vein insertion site.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Fosphenytoin is sometimes used IV instead of phenytoin (Dilantin) because of the number of drug interactions.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">*If Dilantin (Phenytoin) is given IV, it is given slowly at a rate of 50mg/minute.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Safety considerations: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Showers preferred <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Siderails padded <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Waterproof matress pad <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Never swim alone <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Wear helmets during skating, biking <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Medical alert ID <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Child may not drive or operate machinery unless seizure free for a specified amount of time determined state to state.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">*Call 911 if: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">child stops breathing <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">first seizure <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">seizure in water <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">child is unresponsive after <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">child vomits continuously for 30 minutes after <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">pupils are not equal <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">evidence of injury

<span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">Seizure surgery media type="youtube" key="2MKNsI5CWoU" width="560" height="315"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 130%;">Case study: <span style="font-family: 'Times New Roman',Times,serif; font-size: 130%;">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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Neurocerebral: <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Infections of the neurological system:


 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Meningitis - Bacterial and viral **

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Infection affecting the meninges caused by bacteria such as meningococci, pneumococci, and Haemophilus, viral agents or tuberculosis.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Bacterial Meningitis is an infection of the meninges and the CSF. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The Haemophilus vaccine (Act-Hib, Pedvax) and the pneumococcal (Prevnar, PCV 13) have decreased bacterial cases. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">These two bacteria along with Neisseria meningitis (meningococcus) cause 95% of cases older than 2 months of age. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">The meningococcal vaccine (Menactra) is available for ages 11-55 years old.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Incidence <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">1 month and 5 years bacterial <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">school age and adolescents - meningococcal

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pathophysiology <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">This infection generally comes from vascular dissemination from another foci of infection. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Less frequently from the mastoid or paranasal sinuses. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">As in any infectious process exudate (pus) covers the brain and can clog the flow of CSF.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Diagnosis is made by a lumbar puncture. <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Examination of CSF reveals elevated WBCs and protein, while glucose is reduced <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Blood cultures <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Nose and throat cultures. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Ct scan

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Signs and symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Onset may mimic the flu and occur over a couple of days or it may be abrupt. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">fever <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">headache <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">chills <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">irritability <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">agitation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">vomiting <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Photophobia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">nuchal rigidity <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">delirium, stupor and coma may also occur.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 21.969999313354492px;">Infants and young children <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> 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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">InterventionsOutcomes/Management includes:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Isolation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*Septic workup first* <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Antimicrobial therapy: Cephalosporins are drug of choice <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Hydration <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Maintenance of ventilation <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Reduction of increased ICP <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Management of septic shock <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Control of seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Control of temperature <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Treatment of complications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Dexamethasone helps with increased ICP but is not advised for viral meningitis

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">*Complications include shock, disseminated intravascular coagulation syndrome (DIC), seizures, hearing loss, 10-15% fatal

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Nursing care:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Septic workup: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assist with lumbar puncture <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Blood cultures, labs, IV, cath <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assessment: LOC, S&S increased ICP, vital signs (what might I see?), Respiratory distress, I&O, S&S shock, Pain

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Pain control: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Medications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Positioning - No pillow, head of bed slight elevation, side lying often more comfortable

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Comfort: few visitors, low lights, decrease noise and stimuli

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">***Aseptic or viral meningitis is self limiting, it must be differentiated from bacterial and care is supportive***

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Viral Meningitis <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">media type="youtube" key="Ut_vXrDD2hU" width="560" height="315"

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Encephalitis

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 21.969999313354492px;">Herpes simplex encephalitis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> 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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Encephalitis often occurs in hot summer months due to mosquitos.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Signs and symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">similar regardless of the cause - initially flu-like symptoms, gradual or sudden <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">May be mild similar to a mild aseptic meningitis or to a severe case <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">malaise <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">fever <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">headache <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">dizziness <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">apathy <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">nuchal rigidity, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">nausea, vomiting <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">ataxia <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">tremors <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">hyperactivity <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">speech difficulties <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">seizures, disorientation, spasticity, coma and death.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 21.969999313354492px;">Nursing care <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;"> is similar for the child with meningitis

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Reye's Syndrome (RS) <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">defined as Toxic Encephalopathy. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">It is poorly understood but tends to follow a viral illness such as the flu or chicken pox.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Characterized by cerebral edema and changes in the liver. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Link associated between viruses, aspirin, toxins, drugs, genetic factors

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Signs and symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">fever <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">severe hepatic dysfunction: liver complications <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">protracted vomiting: increased ICP <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">neurological impairment which includes personality changes and loss of consciousness (increased ICP)

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Diagnosis: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Liver biopsy provides the definitive diagnosis. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">It is staged I-V. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Elevated ammonia levels <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Early diagnosis and therapy is vital. <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Recovery can be rapid <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">1/3 of the cases end in severe impairment or death.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Nursing care: <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Assist with lumbar puncture <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Blood cultures, labs, IV <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Check LOC, observe for increased ICP <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Possible NG tube, catheter, endotracheal tube <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Monitoring intake and output <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Check coagulation since liver is affected <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Parental teaching about aspirin...viral illnesses

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 20.799999237060547px;">Rabies: CDC rabies link <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Viral - transmitted by bite, scratch, multiplies in muscles so doesn't create antibody/antigen response until its to late <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">88% from wild animals - racoons, skunks, foxes, bats <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">12% domestic animals mostly cats <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Unusual behavior in any animal is suspect <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Bite by any wild animal is considered exposed <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Uncommon in humans <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Incubation 1-3 months but can be as quick as 10 days and as long as 8 months <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Only 10-15% of persons bitten develop disease but once symptoms - fatal <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Long incubation allows time for tx

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22px;">Signs and symptoms: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">malaise <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">fever <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">sore throat <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">hypersensitivity <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">increased rx to external stimuli <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">seizures <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">maniacal behavior <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">choking <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">apnea <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">cyanosis <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">anoxia

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22px;">Treatment: <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Capture animal, hold if domesticated for 10 days <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Cleanse wound <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">*Notify Health department

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Antibiotics <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Tetanus <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Human rabies immune globulins <span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">Human diploid cell rabies vaccine (HDCV)

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Remember the cranium's volume is 80% brain tissue, 10% CSF and 10% blood.
 * <span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">Neurological Injuries: **

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 22.100000381469727px;">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! Here is an excellent article on concussions: @https://www.theverge.com/2017/9/27/16086018/concussion-diary-brain-injury-recovery-symptoms


 * Pathophysiology – ** tearing of nerve fibers, release of acetylcholine and decreased amounts of oxygen

see head injury below
 * Care: **

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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
 * <span style="color: #c31b2e; font-family: 'Times New Roman',Times,serif; font-size: 16pt;">Contusion/laceration **

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


 * http://dontshake.org/ **


 * <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Shaken Baby **

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Young children > skull flexibility However may still tear an artery producing hypovolemic hypotension
 * <span style="color: #c31b2e; font-family: 'Times New Roman',Times,serif; font-size: 16pt;">Fractures **

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

Hemorrhage, edema, infection, herniation, compression Rapidly fatal or slow and insidious
 * <span style="color: #c31b2e; font-family: 'Times New Roman',Times,serif; font-size: 14pt;">Complications: **

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

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

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

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

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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 <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Originates from embryonic cells, Silent, discovered 70% of time after metastasis <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">S&S depend upon the location of the tumor and extent of the disease. Staged form I-IV <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Neuroblastoma staging system 1-2 low risk excellent prognosis, <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">High risk staging with treatment 30-40% survival. The younger child generally fairs better <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Initial treatment focuses on work up and relieving the child's symptoms <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Then chemotherapy and radiation

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<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">References:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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.

<span style="font-family: 'Times New Roman',Times,serif; font-size: 17px;">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.

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Videos:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Meningitis https://youtu.be/URKtW21a9So https://youtu.be/zQmQ5bz_IlY

Viral Meningitis https://youtu.be/Ut_vXrDD2hU

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Dangers of aspirin <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/vOKmQ14Vbho

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Rabies

<span style="color: #d33131; font-family: 'Times New Roman',Times,serif; font-size: 17px;">Videos:

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">How to recognize a concussion <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/wMlpP2dqfW0

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Subarachnoid hemorrhage <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/GPVr_jG-v-s

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Subdural hemorrhage <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/qO16QXMxBLY

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Shaken Baby video <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">http://youtu.be/kgHRWH4USmw

<span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">Drowning <span style="font-family: 'Times New Roman',Times,serif; font-size: 16.899999618530273px;">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