Overview of Pediatric Neurological Dysfunction

Welcome to pediatric neurological dysfunction. Today, we are going to discuss the anatomy and physiology of our neurological system, assessment, intracranial pressure, and procedures, and we'll look at our dysfunction of head injuries, submersion injuries, infections, seizures, and malformations. So first, let's take a look at the brain. Our brain enables a person to reason, function intellectually, express personality and mood, and interact with their environment. The development of the brain begins in the 3rd week of gestation. The brain finishes developing and maturing in the mid to late twenties. Prefrontal cortex is the last to mature. This area is responsible for skills like planning, prioritization, and making good decisions. Our brain coverings, let's start with the cranium which is composed of 8 bones. This helps protect the brain and its associated structures. The galea aponeurotica is thick fibrous band of tissue overlying the cranium which is added protection. The sub galeal space has vagus connections and with increased intracranial pressure, blood can be shunted to this space, reducing the pressure on the intracranial cavity. The cranial vault is irregular and contains many openings for nerves, blood vessels, and spinal cord. Does anyone know what the 3 protective membranes surrounding the brain and spinal cord are called? Collectively meninges. We have our dura mater, our periosteum, and our inner dura. These help support and separate various brain structures. So our brain structures, we have our 3 major divisions, our forebrain, midbrain, and hindbrain. The midbrain, medulla, and pons, medulla and the pons are part of the hindbrain, make up the brain stem which connects the hemispheres of the brain or the forebrain, cerebellum, and spinal cord. Blood brain barrier, what is this? Cellular structures that selectively inhibit certain potentially harmful substances in the blood from the interstitial spaces of the brain and cerebral spinal fluid. This has implications for drug therapy because certain types of antibiotics and chemotherapy agents show a greater propensity than others for crossing this barrier. So our neurological assessment, why is this important? This can tell us if our patient has problems related to the brain. So first, we want to be able to assess our patient's consciousness which is alertness and cognition. Alertness is arousal waking state that includes the ability to respond to stimuli. And cognition is the ability to process stimuli and produce verbal and motor responses. Our vital signs, pulse, respiration, and blood pressure provide information on the adequacy of circulation and the possible underlying cause of altered consciousness. Auto autonomic activity is most intensely intensively disturbed in a deep coma and breaks in lesions. Body temperature is often elevated, sometimes the elevation is extreme. High temperature is the most often a sign of acute infectious process or heat stroke, but it may be caused, but it might may be caused by injection of some drugs especially salicylates, alcohol and barbiturates, or intracranial bleeding especially subarachnoid hemorrhage. Hypothalamic involvement may cause elevated or decreased temperature. Serious infection may produce hypothermia. The pulse can be variable and may be rapid, slow, or bounding, feeble. Blood pressure may be normal, elevated, or very low. Respirations are more often slow, deep, and irregular. Slow and deep breathing often occurs in heavy sleep caused by sedatives after seizures or cerebral infections, slow, shallow breathing may result from sedatives or opioids, hyperventilation which is deep and rapid restorations is usually the result of metabolic acidosis or abnormal stimulation of respiratory center in the medulla caused by psilocytic poisoning, hepaticoma, or Reye's syndrome. The skin. The skin may offer clues about the cause of unconsciousness, the body surface should be examined for injury, fetal marks, petechiae, bites, and even ticks. Evidence of toxic substances may be found on the hands, face, mouth, and clothing especially in small children. Our eyes, assessment of pupil size and reactivity, pupils either do or do not react to light. Panpoint pupils are commonly observed in poisoning such as opiates or barbiturate poisoning or brainstem dysfunction. Widely dilated and reactive pupils are often seen after seizures and may involve one side. Side. Widely dilated and fixed pupils suggest a paralysis of the ocular motor nerve secondary to pressure from herniation. A unilateral fixed pupil usually suggests a lesion on the same side. Bilateral fixed pupils, if pupils if present for more than 5 minutes usually imply brain stim damage. Dilated and non reactive pupils also occur in hypothermia, anoxia, ischemia, poisoning with atropine like substances, or prior installation of myodranic drugs. Some of the therapies used such as barbiturates can alter pupil size and reaction. The sudden appearance of fixed and dilated pupils is a neurosurgery emergency. Motor function observation of spontaneous activity, posture in response to painful stimuli provides clues to location and extent of cerebral dysfunction. Asymmetrical movements of the limbs or the absence of movement suggests paralysis. Posturing. Flexion posturing occurs with severe dysfunction of the cerebral cortex or with lesions to the corticospinal tracts above the brain stem. Extension posturing is a sign of dysfunction at the level of the midbrain or lesions of the brain stem. Reflexes. 3 key reflexes that demonstrate neurological health in young infants are the moral, tonic neck, and withdrawal reflexes. Neurological assessment continued. We have our Glasgow Coma Scale. This is scored between a 3 and 15. With 3 being the worst and 15 being the best. It is composed of 3 parameters, best eye response, best verbal response, and best motor response. The The components of the Glasgow Glaucoma Scale should be recorded individually. A score of 13 or higher correlates with midbrain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. The pediatric colascoma scale is validated in children 2 years of age or younger. So as you can see on the screen, we have your eye opening. Is it spontaneous to sound, to pain, or if they're done? Our verbal response, age appropriate vocalizations, style orientation to sound, interact such as coos or babbles, and follows objects, cries, irritable, cries to pain, bones to pain, murders that. And then our motor response, spontaneous movements may obey verbal commands, withdraws to touch, vocalizes pain, withdraws to pain, abnormal reflection to pain, and abnormal extension to pain. Intercranial pressure. So on the screen, you can see the different signs and symptoms of increased intracranial pressure for both infants and children. The brain is tightly enclosed in a solid bony cranium, is well protected but highly vulnerable to pressure that may accumulate within the enclosure. If an infant falls and hits their head, as a nurse a concerning sign would be the tense, bulging fontanelle. Children with open fontanelles compensate for increased volume by skull expansion and widened sutures. However, at any age, the capacity for special compensation is limited. An increase in intracranial pressure may be caused by tumors or other space occupying lesions, accumulation of fluid within the ventricular system, bleeding or edema in the cerebral tissues. Once it's compensated, its compensation is exhausted, any further increased volume results in rapid rise of intracranial pressure. Pressure. The early signs and symptoms of intracranial pressure such as headache, poverty, personality changes, irritability, and fatigue are often often several. In older children, subjective symptoms are headache, especially when a rising upper right leg, such as a wakening in the morning or when coughing, sneezing, or bending over, and nausea and vomiting. The child may complain of double vision or blurry vision with movement at the head. Seizures may occur. In children whose cranial sutures have not closed, there's an increase in head circumference and tense or bulging fondness. Cranial sutures may be wide, head circumference can enlarge until a child is 5 years of age if the condition progresses slowly. As pressure increases, the pupils become progressively sluggish in reaction and eventually become fixed and dilated. The level of consciousness progressively deteriorates from drowsiness to eventual coma. Problems related to intracranial pressure are discussed later related to head injury and hydrocephalus. So what are our late signs of increased intracranial pressure in infants and children? What are our Cushing Triad symptoms? They're highlighted on the screen. Our bradycardia, our irregular respirations, and our system systematic hypertension. This is a medical emergency. You may need to decrease the intracranial pressure and reverse the cause. IV mannitol is a diuretic that can help elevate the head of the bed and in oxygenation and ventilation. So our nursing care. Respiratory effectiveness is the primary concern in the care for the unconscious child, and establishment of an adequate airway is always a first priority. Carbon dioxide has a potent vasodilating effect and will increase cerebral blood flow and intracranial pressure. Cerebral hypoxia is at a normal body temperature that lasts longer than 4 minutes often causes irreversible brain damage. Continual observation of level of consciousness at pupillary pupillary pupil reaction in vital signs is essential to management of CNS disorders. Regular assessment of neurological status and vital signs is an integral part of the nursing care of the unconscious children. The frequency depends on the cause of the unconsciousness. The level of consciousness and progression of cerebral involvement intervals between observation may be short as 15 minutes or as long as every 2 hours. Significant alterations are reported immediately. The temperature is measured every 2 to 4 hours depending on the child's condition. An elevated temperature may occur in children with CNS dysfunction, therefore a light covering may be sufficient. Bigger vigorous efforts such as T Big Sponge Baths or application of hypothermic blanket are needed to prevent brain damage if the rectal temperature exceeds a 104 degrees Fahrenheit. Elevate the head of the bed to 15 to 30 degrees, and position the child so that the head is maintained in a midline to facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated because of the risk of jugular compression. It is important to avoid activities that may increase intracranial pressure by causing pain or emotional stress, clustering nursing activities together, and minimizing environmental stimuli by decreasing noxious procedures help control intracranial pressure. Range of motion exercises can be carried out gently, but should not be performed vigorously. Any necessary disturbing procedures should be scheduled to take advantage of therapies that reduce intracranial pressure such as osmol therapy and sedation. These are different procedures. This is also located have our lumbar puncture, a schoptery cuff, our ventricle puncture, an EEG, and a nuclear brain scan. The next slide, we have our radiography, our CT scans, our MRI, and our PET scans. Recommend reviewing these. Pet injury is a pathological process involving the scalp, skull, meninges, or brain as a result of mechanical force. The most common cause of head injury in children are false. Being struck by or striking an object with one's head and motor vehicle accidents. Unintentional injuries are the number one health risk for children and the leading cause of death in children older than 1 year of age. Assaults are the leading cause of death in from traumatic brain injury in children 4 years of age younger. If a child loses consciousness or develops a severe headache after a head injury, medical attention should be sought. SIADH and DI, we've talked a little bit about these in our endocrine lecture. What is SIADH? It's a syndrome of inappropriate antidiuretic hormone secretion. And what is DI? Diabetes Insipidus. Central diabetes insipidus may result from a number of different causes. Primary causes are familial or idiopathic of the total of the total number of cases approximately 20 to 50 percent are idiopathic. Secondary causes include trauma, accidental or surgical, tumors, infections such as meningitis or encephalitis, and vascular anomalies such as aneurysms. Certain drugs such as alcohol or phenytoin can cause a transient polyuria. Diabetes incipidus may be an early sign of an evolving cerebral process. SIADH and DI often accompanies CNS conditions such as head injury, meningitis, encephalitis, brain abscess, brain tumor, or subarachnoid hemorrhage. What does SIADH look like? What does our patient look like? Well, they have fluid retention and hyponatremia. Hyponatremia, they might be edematous, hypo osmolality, potentially low urine. You should not be confused with dehydration. And what does DI look like? Diabetes insipidus, polyuria, polydipidus. Treatment of diabetes insipidus is hormone replacement using DDAVP. VB, SIADH, treatment is fluid restriction, medications such as sodium chloride up to 3% saline, and diuretics may be used. Diabetes insipidus and an early sign of DI may be in Muresis in a child who is toilet trained. Excessive thirst with concurrent bed wetting indicates further investigation. Nursing assessment includes frequent measurements of a patient's weight, serum electrolytes, BUN, hematocrit, and urine specific gravity. Fluid intake and output should be measured frequently and recorded. Other patients are able to adjust fluid intake, but unconscious or very young patients require closer fluid observation. In a child who are toilet trained, collection of urine specimens may require application of urine collecting devices. After confirmation of diabetes insipidus, parenting comprehensive teaching. Specific clarification that diabetes insipidus is different condition than diabetes mellitus should be reinforced. Parents and children must realize that this is a lifelong treatment. Caregivers should be taught the correct procedure for preparation and administration of vasopressin. When children are old enough, they should be encouraged to assume full responsibility for their care. For emergency purposes, children with diabetes exhibited should wear a medical alert identification. Subversion injuries. Injuries. Drowning is the leading cause of death for children. In the United States more children ages 1 to 4 die from drowning than any other cause of death. For children ages 5 to 14 drowning is the second leading cause of unintentional injury after motor vehicle crashes. Most cases of subversion injury are accidental, usually involving children who are helpless in water such as inadequate fully attended children in or near swimming pools, infants in bathtubs, small children who fall into ponds or streams, occupants of boats who fail to wear life preservers, children who have diving accidents, and children who are are able to swim but overestimate their endurance. Accidental submersion injury occurs predominantly in males, toddlers, and African Americans. Submersion injury can take place in any body of water. Children less than 1 year of age are more likely to have a submersion injury in a bathtub, whereas top heavy toddlers fall headfirst into a pail of water and unable to free themselves. Preschoolers are at risk for injury in swimming pools, and school age children and adolescents are most commonly at risk in natural body fluids and water such as lakes, ponds, and rivers. Homicidal Submersion injuries are not witnessed, usually occur in the home, and the victims are either infants or toddlers. All children who have a submersion injury should be admitted to the hospital for observation, although many patients do not appear to have suffered adverse events effects from the event. Complications, such as respiratory compromise and cerebral edema, may occur 24 hours after the incident. Major problems caused by submersion injuries include hypoxia, aspiration, and hypothermia. So how do we prevent this? Most submersion injuries are preventable. The most common cause of submersion injuries in infants and young children is inadequate adult supervision, including a momentary lapse of supervision. Parents are unaware that they must be within arms reach and constantly supervising without being distracted. Nurses can be active advocates in their communities. Nurses are in a position to emphasize the importance of adequate adult supervision when children are around any body of water and should include the necessity of the adult not engaging in distracting activities. Neurological infections. We're gonna review bacterial meningitis, nonbacterial meningitis, tuberculosis. Meningitis, brain abscess, encephalitis, rabies, and wrack syndrome. Intracranial infections. The nervous system is subject to infections by the same organisms that affect any other organs in the body. However, the nervous system is limited in many in the ways in which it responds to the injury. Laboratory studies are needed to identify the causative agent. The inflammatory process can affect the meninges, meningitis, or brain, encephalitis. Meningitis can be caused by a variety of organisms, but there are 3 main types. Bacteria caused by pus forming bacteria, especially meningococcal or pneumococcal organisms, viral or aseptic, caused by a wide variety of viral agents and tuberculosis. The majority of children with acute febrile encephalopathy have bacterial meningitis or viral meningitis as the underlying cause. Bacterial meningitis is an acute inflammation of the meninges and central spinal fluid. The introduction of conduit vaccines against hemophilus influenza b, type b, hip vaccine, in 1990 and streptococcus pneumonia in 2000 has led to dramatic changes in the epidemiology of bacterial meningitis. Today, the Hib infection has been virtually eradicated among young children in areas where the Hib vaccine is administered routinely. The most common bacterial meningitis caused for mutinase is group b streptococcus, and for children 3 months to 11 years of age is, esthemonia. Any child who is ill and develops a tequila or a burrow rash may have a meningococcal cysteine in there. They must and must receive immediate medical attention. Fever, forfeiting, photophobia, irritability are all signs and treatment. So a lung blood function is a definitive diagnostic test. The fluid pressure is measured, and samples are obtained for culture, gram stain, blood cell count, and determination of glucose and protein levels. Acute bacterial meningitis is a medical emergency that requires early recognition and immediate therapy to prevent death and void residual disabilities. Initial therapeutic management includes the following, isolation precautions, initiation of antimicrobial therapy, maintenance main maintenance of hydration, maintenance of ventilation, reduce the incidence of increase in cranial pressure, management of systemic shock, control of seizures, control of temperature, treatment of complications. Our nursing care, we are to keep the room as quiet as possible and environmental stimulant at a minimum as most children with meningitis are sensitive to noise, bright lights, and other external stimuli. Help the family limit the number and frequency of visitors until the child is and feels better. Most children are more comfortable with a pillow under their head, but with the head of the bed slightly elevated. The term aseptic meningitis refers to the onset of meningeal symptoms such as fever, plasiositis, without bacterial growth from CSF cultures. Aseptic meningitis is caused by many different viruses, including arbovirus, enterovirus, herpes simplex virus, spinnomegalovirus, and human effecient. Human immunodeficiency virus. Enterovirus is the most common cause of of atopic meningitis. The onset may be abrupt or gradual, and many of the presenting symptoms signs and symptoms are the same as bacterial meningitis, including headache, fever, photophobia, and nuchal rigidity. What's our nursing care? Again, it's very similar to our bacterial meningitis. Keep the room as quiet as possible and environmental stimulate at a minimum as most children with meningitis are sensitive to noise, bright legs, and external stimuli. Also, keep the head of the bed elevated. Derivulocyst meningitis must be considered in children who have traveled to or lived in developing countries or who live with or are immigrants from developing countries. In 2015, the incidence of tuberculosis meningitis in the United States increased for the first time in more than 2 decades. Tuberculosis meningitis is most likely to be disseminated in very young or immunosuppressed children. A ischemic infarction can occur with rurgulos meningitis. The most common clinical findings are meningeal signs, fever, altered consciousness, central nervous system involvement, seizures, and focal neurological deficit. Brain abscess. Intracerebral abscesses form when pyogenic organisms gain access to the neural tissue by the way of the bloodstream from foci of infection or direct inoculation of organisms from infections, penetrating trauma, or surgical procedures. Chronic ear infection, mastoiditis, sinusitis, and congenital heart disease are the most common predisposing factors for children with brain abscess. The majority, about 70% of brain abscesses are caused by anaerobic or aerobic streptococci. In neonates, Citrobacter is the most common, and fungi are more common in immunosuppressed children. The most common sites of intracerebral abscesses are the peritoneal, temporal, and frontal lobes. Early signs of the disease are vague. However, the most common symptom is a severe headache. Encephalitis is the inflammatory process of the central nervous system that is caused by a variety of organisms, including bacteria, fungi, protozoa, and viruses. Most infections are associated with viruses, and this discussion is limited to those agents. The clinical features of encephalitis are similar regardless of the agent involved. Manifestations can range from mild benign form that resembles aseptic meningitis, lasts a few days, and is followed by a rapid and complete recovery to a rapid progressing encephalitis with severe central nervous system involvement. The onset may be sudden or maybe gradual with malaise, fever, headache, dizziness, apathy, mucovrigidity, nausea and vomiting, ataxia, tremors, hyperactivity, and speech difficulties. What's our therapeutic management? Patients affected of having encephalitis are hospitalized properly for observation, including intracranial pressure monitoring. In autoimmune encephalitis, rapid initiation of immunotherapy, including corticosteroids, osmophoresis, and IV immunoglobulin improves outcome. Herpes simplex virus encephalitis is the only viral encephalitis that has specific treatment available. Bradetes is an acute infection of the nervous system caused by a virus that's almost invariably fatal if left untreated. It is transmitted to humans by the saliva of the infected mammal introduced through bitten or through a bite or skin abrasion. After entry into a new host, the virus multiplies its muscle cells and is spread through the neural pathways without stimulating a protective host immune response. Through dog vaccination, rabies from dog bites has been eliminated in the United States. Carnivorous wild animals such as raccoons, skunks, bat, and foxes are the animals most often infected with rabies and the cause of the most indigenous cases of human rabies in the United States. Educate about unusual behavior in the animal is cause for suspicion. Children should be warned to be aware of wild animals that appear appear to be friendly. The current therapy for a rabid animal bite consists of 3 steps, thorough cleansing of the wound with soap and water, administration of rabies vaccine, and administration of rabies immunoglobulin. The rabies vaccine and immunoglobulin should be initiated as soon as possible after exposure. Reye's syndrome is a disorder defined as metabolic encephalopathy associated with other characteristic characteristic organ involvement. It is characterized by fever, profoundly impaired consciousness, and disordered somatic function. The etiology of Reye's syndrome is not well understood for most cases follow a common viral illness, typically influenza or varicella. Reye's syndrome is a condition characterized by pathologically by cerebral edema and fatty changes in the liver. The onset of Ryerson is notable for perfuse, effortless, vomiting, and lethargy that quickly progress to neurological impairment, including delirium, seizures, and coma, and can ultimately lead to increased intracranial pressure, herniation, and death. The cause of Reye's syndrome is mitochondrial insult and induced by various viruses, drugs, exotoxins, and genetic factors. Elevated serum ammonia levels tend to correlate with the clinical manifestations and prognosis. Definitive diagnosis is established by liver biopsy. The safety criteria for Reye's syndrome are based on liver dysfunction and on neurological signs that range from lethargy to coma. As a result of improved diagnostic techniques, children who in the past would have been diagnosed with Reye's syndrome are now diagnosed with other illnesses such as viral or inborn errors of metabolism, Causes of unrecognized drug induced encephalopathy by antiemetics given to children during viral illnesses have symptoms similar to those of Reye's syndrome. A potential associated between aspirin therapy for the treatment of fever in children with varicella or influenza and the development of Reye syndrome precludes its use in these patients. However, by the time the FDA required aspirin product laboring in 1986, most of the decline in Reye's syndrome incidents had already occurred. Care and observation are implemented as for any child with an altered state of consciousness and increasing intracranial pressure. Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Because of the related liver dysfunction, monitoring lab studies to determine impaired coagulation, such as prolonged bleeding time. Keep the parents of the children with Reye's syndrome informed of the child's progress and explain diagnostic procedures and therapeutic management. Recovery from Reye's syndrome is rapid and usually without sequelae. If the diagnosis is determined early and the therapy is initiated properly. Patients who survive have full liver function recovery. Seizures and epilepsy. Please view the video, that is in the module for more information on seizures. A seizure is a transient occurrence of signs and or symptoms due to abnormal excessive or synchronous neuronal activity in the brain. The manifestation of seizure depends on the region of the brain in which they originate and may include unconscious or altered consciousness, involuntary movements, and changes in perception, behaviors, sensations, and or posture. Seizures are the symptom of underlying disease process. They are in individual events. Potential causes include infections, intracranial lesion or hemorrhage, metabolic disorders, trauma, brain malformations, genetic disorders, or toxic ingestion. The goal of treatment of a seizure disorder is to control the seizures or reduce the goal of treatment of a seizure disorder is to control the seizures or reduce their frequency and severity and discover and correct the cause whenever possible and help the child live as normal of a life as possible. An important nursing responsibility is to observe the seizure episode and accurately document the events. Record any alterations in behavior preceding the seizure and the characteristics of the episode, such as sensory hallucination phenomena or aura, motor effects, eye movements, muscular contractions, or alterations in consciousness and post atrial state. The nurse should describe only what is observed rather than try to label a seizure type. Note that the time the seizure began and the duration of the seizure. Generalized seizures and other types with clear manifestations are easy to detect, but absent seizures may be more may present more difficulties. They usually are misinterpreted as inattention. Any unusual behavior, even seemingly inconsequential, such as momentary interruption of activity, staring, or mental blankness, should be described. The more detailed these descriptions, the more valuable they are for assessment. And safety is a big concern for these patients as well. If a child is actively seizing, you would not move the child from the floor to the bed. Headaches. Primary headaches are classified as migraine, tension type headaches, and other primary headache disorders. A migraine is one of the top 5 common childhood diseases. Migraines have can have their onset in very young children, including infants when they are when they manifest as colic. The onset tends to be earlier in boys than girls until puberty when girls have a twofold increase over boys and migraines. This is thought to be due to the effects of estrogen. A secondary headache is caused from another condition and should be resolved once the underlying condition is treated. Headaches can be a result of conditions such as traumatic brain injury, brain tumor, brain infection, cerebrovascular disorders, withdrawal from or exposure to substances, vision problems, hunger, psychiatric disorders, and medication overuse. It is important to determine the headache the pattern of the headache, acute, acute recurrent, chronic progressive, or chronic nonprogressive. The assessment information includes the presence of seizures, ataxia, lethargy, weakness, nausea and vomiting, and or personality changes. Factors related to early development and past illnesses and a family history of headaches may also be pertinent. A headache diary, which includes time and onset, determination of headaches, intensity, associated events, and actions taken, and their effort effects can be helpful for the patient and provider. If a child has a headache that wakes them up at night, they should be seen immediately. Hydrocephalus is a condition caused by imbalance in the production or absorption of the central spital fluid, or CSF, in the ventricular system. The cause of hydrocephalus are varied and include either congenital or acquired conditions The result is either impaired absorption of CSF fluid with the sub within the subarachnoid space, obliteration of the subarachnoid cisterns and malformation of the arachnoid villi, or obstruction to the flow of the CSF to the ventricular system. Chiari 1 and Chiari 2 malformations are structural defects in the base of the skull on the cerebellum. They occur when the lower cerebellum extends below the boremum magnum and into the sup upper spinal canal, sherry 1. Over the lower cerebellum and the brain distributes into the spinal canal through the enlarged boremum magnum, maca, TRI 2. TRI malformation does not usually cause hydrocephalus. It is usually asymptomatic until adolescence when it can cause headaches, neck pain, frequent urination, and lower limb progressive spasticity. Type 2 TRM malformation is seen almost exclusively with myelomeningocele and results in obstruction of the CSF flow causing hydrocephalus. So what's our therapeutic management? We want to treat the hydrocephalus as directed toward relief of the ventricular fracture, treatment of the cause of the ventricle magaly, treatment of associated complications, and management of problems related to the effect of the disorder on psychomotor development. The treatment with few exceptions is usually surgical. So improved neurosurgical techniques have established surgical treatment as the therapy of choice in almost all cases of hydrocephalus. This is accomplished by direct removal of an obstruction, such as resect of a neoplasm, a cyst, or hematoma, or rare incidences of fluid overproduction. However, most children require a shunt procedure that provides primary drainage of the CSF from the ventriculars to an extracranial compartment, usually in the peritoneal. The singular procedure for many years has been a VP or ventral peritoneal shunt, especially in neonates and young infants. There is a greater allowance of excess tubing which minimizes the number of revisions needed as the child grows. Because it requires repeated lengthening, the ventral atrial shunt is reserved for older children who have attained most of their somatic growth and children who have children with cardiopulmonary disease or elevated CSF protein. What are our complications? The major complications of a VP shunt are infection and malfunction. All shunts are subject to mechanical difficulties such as kinking, plugging, or separation in migration of tubing. Education for the family could include: to prepare the child for discharge at home care, instruct the parents on how to recognize signs and symptoms that indicate child malfunction or infection. Active children may have injuries such as fall that can damage the shunt, and the tubing may pull out of the distal insertion site or become disconnected during normal growth. Contact sports such as football, rugby, boxing, and wrestling are prohibited if a person has a BP shunt. Other sports, such as swimming, soccer, and track, are usually acceptable and even encouraged for the child's physical and emotional health. Thank you for listening to this presentation on pediatric neurological conditions. Presentation on pediatric neurological conditions.

The brain finishes developing and maturing in the mid to late twenties. Prefrontal cortex is the last to mature. This area is responsible for skills like planning, prioritization, and making good decisions. Our brain coverings, let's start with the cranium which is composed of 8 bones. This helps protect the brain and its associated structures.

The galea aponeurotica is thick fibrous band of tissue overlying the cranium which is added protection. The sub galeal space has vagus connections and with increased intracranial pressure, blood can be shunted to this space, reducing the pressure on the intracranial cavity. The cranial vault is irregular and contains many openings for nerves, blood vessels, and spinal cord. Does anyone know what the 3 protective membranes surrounding the brain and spinal cord are called? Collectively meninges.

We have our dura mater, our periosteum, and our inner dura. These help support and separate various brain structures. So our brain structures, we have our 3 major divisions, our forebrain, midbrain, and hindbrain. The midbrain, medulla, and pons, medulla and the pons are part of the hindbrain, make up the brain stem which connects the hemispheres of the brain or the forebrain, cerebellum, and spinal cord. Blood brain barrier, what is this?

Cellular structures that selectively inhibit certain potentially harmful substances in the blood from the interstitial spaces of the brain and cerebral spinal fluid. This has implications for drug therapy because certain types of antibiotics and chemotherapy agents show a greater propensity than others for crossing this barrier. So our neurological assessment, why is this important? This can tell us if our patient has problems related to the brain. So first, we want to be able to assess our patient's consciousness which is alertness and cognition.

Alertness is arousal waking state that includes the ability to respond to stimuli. And cognition is the ability to process stimuli and produce verbal and motor responses. Our vital signs, pulse, respiration, and blood pressure provide information on the adequacy of circulation and the possible underlying cause of altered consciousness. Auto autonomic activity is most intensely intensively disturbed in a deep coma and breaks in lesions. Body temperature is often elevated, sometimes the elevation is extreme.

High temperature is the most often a sign of acute infectious process or heat stroke, but it may be caused, but it might may be caused by injection of some drugs especially salicylates, alcohol and barbiturates, or intracranial bleeding especially subarachnoid hemorrhage. Hypothalamic involvement may cause elevated or decreased temperature. Serious infection may produce hypothermia. The pulse can be variable and may be rapid, slow, or bounding, feeble. Blood pressure may be normal, elevated, or very low.

Respirations are more often slow, deep, and irregular. Slow and deep breathing often occurs in heavy sleep caused by sedatives after seizures or cerebral infections, slow, shallow breathing may result from sedatives or opioids, hyperventilation which is deep and rapid restorations is usually the result of metabolic acidosis or abnormal stimulation of respiratory center in the medulla caused by psilocytic poisoning, hepaticoma, or Reye's syndrome. The skin. The skin may offer clues about the cause of unconsciousness, the body surface should be examined for injury, fetal marks, petechiae, bites, and even ticks. Evidence of toxic substances may be found on the hands, face, mouth, and clothing especially in small children.

Our eyes, assessment of pupil size and reactivity, pupils either do or do not react to light. Panpoint pupils are commonly observed in poisoning such as opiates or barbiturate poisoning or brainstem dysfunction. Widely dilated and reactive pupils are often seen after seizures and may involve one side. Side. Widely dilated and fixed pupils suggest a paralysis of the ocular motor nerve secondary to pressure from herniation.

A unilateral fixed pupil usually suggests a lesion on the same side. Bilateral fixed pupils, if pupils if present for more than 5 minutes usually imply brain stim damage. Dilated and non reactive pupils also occur in hypothermia, anoxia, ischemia, poisoning with atropine like substances, or prior installation of myodranic drugs. Some of the therapies used such as barbiturates can alter pupil size and reaction. The sudden appearance of fixed and dilated pupils is a neurosurgery emergency.

Motor function observation of spontaneous activity, posture in response to painful stimuli provides clues to location and extent of cerebral dysfunction. Asymmetrical movements of the limbs or the absence of movement suggests paralysis. Posturing. Flexion posturing occurs with severe dysfunction of the cerebral cortex or with lesions to the corticospinal tracts above the brain stem. Extension posturing is a sign of dysfunction at the level of the midbrain or lesions of the brain stem.

Reflexes. 3 key reflexes that demonstrate neurological health in young infants are the moral, tonic neck, and withdrawal reflexes. Neurological assessment continued. We have our Glasgow Coma Scale. This is scored between a 3 and 15.

With 3 being the worst and 15 being the best. It is composed of 3 parameters, best eye response, best verbal response, and best motor response. The The components of the Glasgow Glaucoma Scale should be recorded individually. A score of 13 or higher correlates with midbrain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. The pediatric colascoma scale is validated in children 2 years of age or younger.

So as you can see on the screen, we have your eye opening. Is it spontaneous to sound, to pain, or if they're done? Our verbal response, age appropriate vocalizations, style orientation to sound, interact such as coos or babbles, and follows objects, cries, irritable, cries to pain, bones to pain, murders that. And then our motor response, spontaneous movements may obey verbal commands, withdraws to touch, vocalizes pain, withdraws to pain, abnormal reflection to pain, and abnormal extension to pain. Intercranial pressure.

So on the screen, you can see the different signs and symptoms of increased intracranial pressure for both infants and children. The brain is tightly enclosed in a solid bony cranium, is well protected but highly vulnerable to pressure that may accumulate within the enclosure. If an infant falls and hits their head, as a nurse a concerning sign would be the tense, bulging fontanelle. Children with open fontanelles compensate for increased volume by skull expansion and widened sutures. However, at any age, the capacity for special compensation is limited.

An increase in intracranial pressure may be caused by tumors or other space occupying lesions, accumulation of fluid within the ventricular system, bleeding or edema in the cerebral tissues. Once it's compensated, its compensation is exhausted, any further increased volume results in rapid rise of intracranial pressure. Pressure. The early signs and symptoms of intracranial pressure such as headache, poverty, personality changes, irritability, and fatigue are often often several. In older children, subjective symptoms are headache, especially when a rising upper right leg, such as a wakening in the morning or when coughing, sneezing, or bending over, and nausea and vomiting.

The child may complain of double vision or blurry vision with movement at the head. Seizures may occur. In children whose cranial sutures have not closed, there's an increase in head circumference and tense or bulging fondness. Cranial sutures may be wide, head circumference can enlarge until a child is 5 years of age if the condition progresses slowly. As pressure increases, the pupils become progressively sluggish in reaction and eventually become fixed and dilated.

The level of consciousness progressively deteriorates from drowsiness to eventual coma. Problems related to intracranial pressure are discussed later related to head injury and hydrocephalus. So what are our late signs of increased intracranial pressure in infants and children? What are our Cushing Triad symptoms? They're highlighted on the screen.

Our bradycardia, our irregular respirations, and our system systematic hypertension. This is a medical emergency. You may need to decrease the intracranial pressure and reverse the cause. IV mannitol is a diuretic that can help elevate the head of the bed and in oxygenation and ventilation. So our nursing care.

Respiratory effectiveness is the primary concern in the care for the unconscious child, and establishment of an adequate airway is always a first priority. Carbon dioxide has a potent vasodilating effect and will increase cerebral blood flow and intracranial pressure. Cerebral hypoxia is at a normal body temperature that lasts longer than 4 minutes often causes irreversible brain damage. Continual observation of level of consciousness at pupillary pupillary pupil reaction in vital signs is essential to management of CNS disorders. Regular assessment of neurological status and vital signs is an integral part of the nursing care of the unconscious children.

The frequency depends on the cause of the unconsciousness. The level of consciousness and progression of cerebral involvement intervals between observation may be short as 15 minutes or as long as every 2 hours. Significant alterations are reported immediately. The temperature is measured every 2 to 4 hours depending on the child's condition. An elevated temperature may occur in children with CNS dysfunction, therefore a light covering may be sufficient.

Bigger vigorous efforts such as T Big Sponge Baths or application of hypothermic blanket are needed to prevent brain damage if the rectal temperature exceeds a 104 degrees Fahrenheit. Elevate the head of the bed to 15 to 30 degrees, and position the child so that the head is maintained in a midline to facilitate venous drainage and avoid jugular compression. Turning side to side is contraindicated because of the risk of jugular compression. It is important to avoid activities that may increase intracranial pressure by causing pain or emotional stress, clustering nursing activities together, and minimizing environmental stimuli by decreasing noxious procedures help control intracranial pressure. Range of motion exercises can be carried out gently, but should not be performed vigorously.

Any necessary disturbing procedures should be scheduled to take advantage of therapies that reduce intracranial pressure such as osmol therapy and sedation. These are different procedures. This is also located have our lumbar puncture, a schoptery cuff, our ventricle puncture, an EEG, and a nuclear brain scan. The next slide, we have our radiography, our CT scans, our MRI, and our PET scans. Recommend reviewing these.

Pet injury is a pathological process involving the scalp, skull, meninges, or brain as a result of mechanical force. The most common cause of head injury in children are false. Being struck by or striking an object with one's head and motor vehicle accidents. Unintentional injuries are the number one health risk for children and the leading cause of death in children older than 1 year of age. Assaults are the leading cause of death in from traumatic brain injury in children 4 years of age younger.

If a child loses consciousness or develops a severe headache after a head injury, medical attention should be sought. SIADH and DI, we've talked a little bit about these in our endocrine lecture. What is SIADH? It's a syndrome of inappropriate antidiuretic hormone secretion. And what is DI?

Diabetes Insipidus. Central diabetes insipidus may result from a number of different causes. Primary causes are familial or idiopathic of the total of the total number of cases approximately 20 to 50 percent are idiopathic. Secondary causes include trauma, accidental or surgical, tumors, infections such as meningitis or encephalitis, and vascular anomalies such as aneurysms. Certain drugs such as alcohol or phenytoin can cause a transient polyuria.

Diabetes incipidus may be an early sign of an evolving cerebral process. SIADH and DI often accompanies CNS conditions such as head injury, meningitis, encephalitis, brain abscess, brain tumor, or subarachnoid hemorrhage. What does SIADH look like? What does our patient look like? Well, they have fluid retention and hyponatremia.

Hyponatremia, they might be edematous, hypo osmolality, potentially low urine. You should not be confused with dehydration. And what does DI look like? Diabetes insipidus, polyuria, polydipidus. Treatment of diabetes insipidus is hormone replacement using DDAVP.

VB, SIADH, treatment is fluid restriction, medications such as sodium chloride up to 3% saline, and diuretics may be used. Diabetes insipidus and an early sign of DI may be in Muresis in a child who is toilet trained. Excessive thirst with concurrent bed wetting indicates further investigation. Nursing assessment includes frequent measurements of a patient's weight, serum electrolytes, BUN, hematocrit, and urine specific gravity. Fluid intake and output should be measured frequently and recorded.

Other patients are able to adjust fluid intake, but unconscious or very young patients require closer fluid observation. In a child who are toilet trained, collection of urine specimens may require application of urine collecting devices. After confirmation of diabetes insipidus, parenting comprehensive teaching. Specific clarification that diabetes insipidus is different condition than diabetes mellitus should be reinforced. Parents and children must realize that this is a lifelong treatment.

Caregivers should be taught the correct procedure for preparation and administration of vasopressin. When children are old enough, they should be encouraged to assume full responsibility for their care. For emergency purposes, children with diabetes exhibited should wear a medical alert identification. Subversion injuries. Injuries.

Drowning is the leading cause of death for children. In the United States more children ages 1 to 4 die from drowning than any other cause of death. For children ages 5 to 14 drowning is the second leading cause of unintentional injury after motor vehicle crashes. Most cases of subversion injury are accidental, usually involving children who are helpless in water such as inadequate fully attended children in or near swimming pools, infants in bathtubs, small children who fall into ponds or streams, occupants of boats who fail to wear life preservers, children who have diving accidents, and children who are are able to swim but overestimate their endurance. Accidental submersion injury occurs predominantly in males, toddlers, and African Americans.

Submersion injury can take place in any body of water. Children less than 1 year of age are more likely to have a submersion injury in a bathtub, whereas top heavy toddlers fall headfirst into a pail of water and unable to free themselves. Preschoolers are at risk for injury in swimming pools, and school age children and adolescents are most commonly at risk in natural body fluids and water such as lakes, ponds, and rivers. Homicidal Submersion injuries are not witnessed, usually occur in the home, and the victims are either infants or toddlers. All children who have a submersion injury should be admitted to the hospital for observation, although many patients do not appear to have suffered adverse events effects from the event.

Complications, such as respiratory compromise and cerebral edema, may occur 24 hours after the incident. Major problems caused by submersion injuries include hypoxia, aspiration, and hypothermia. So how do we prevent this? Most submersion injuries are preventable. The most common cause of submersion injuries in infants and young children is inadequate adult supervision, including a momentary lapse of supervision.

Parents are unaware that they must be within arms reach and constantly supervising without being distracted. Nurses can be active advocates in their communities. Nurses are in a position to emphasize the importance of adequate adult supervision when children are around any body of water and should include the necessity of the adult not engaging in distracting activities. Neurological infections. We're gonna review bacterial meningitis, nonbacterial meningitis, tuberculosis.

Meningitis, brain abscess, encephalitis, rabies, and wrack syndrome. Intracranial infections. The nervous system is subject to infections by the same organisms that affect any other organs in the body. However, the nervous system is limited in many in the ways in which it responds to the injury. Laboratory studies are needed to identify the causative agent.

The inflammatory process can affect the meninges, meningitis, or brain, encephalitis. Meningitis can be caused by a variety of organisms, but there are 3 main types. Bacteria caused by pus forming bacteria, especially meningococcal or pneumococcal organisms, viral or aseptic, caused by a wide variety of viral agents and tuberculosis. The majority of children with acute febrile encephalopathy have bacterial meningitis or viral meningitis as the underlying cause. Bacterial meningitis is an acute inflammation of the meninges and central spinal fluid.

The introduction of conduit vaccines against hemophilus influenza b, type b, hip vaccine, in 1990 and streptococcus pneumonia in 2000 has led to dramatic changes in the epidemiology of bacterial meningitis. Today, the Hib infection has been virtually eradicated among young children in areas where the Hib vaccine is administered routinely. The most common bacterial meningitis caused for mutinase is group b streptococcus, and for children 3 months to 11 years of age is, esthemonia. Any child who is ill and develops a tequila or a burrow rash may have a meningococcal cysteine in there. They must and must receive immediate medical attention.

Fever, forfeiting, photophobia, irritability are all signs and treatment. So a lung blood function is a definitive diagnostic test. The fluid pressure is measured, and samples are obtained for culture, gram stain, blood cell count, and determination of glucose and protein levels. Acute bacterial meningitis is a medical emergency that requires early recognition and immediate therapy to prevent death and void residual disabilities. Initial therapeutic management includes the following, isolation precautions, initiation of antimicrobial therapy, maintenance main maintenance of hydration, maintenance of ventilation, reduce the incidence of increase in cranial pressure, management of systemic shock, control of seizures, control of temperature, treatment of complications.

Our nursing care, we are to keep the room as quiet as possible and environmental stimulant at a minimum as most children with meningitis are sensitive to noise, bright lights, and other external stimuli. Help the family limit the number and frequency of visitors until the child is and feels better. Most children are more comfortable with a pillow under their head, but with the head of the bed slightly elevated. The term aseptic meningitis refers to the onset of meningeal symptoms such as fever, plasiositis, without bacterial growth from CSF cultures. Aseptic meningitis is caused by many different viruses, including arbovirus, enterovirus, herpes simplex virus, spinnomegalovirus, and human effecient.

Human immunodeficiency virus. Enterovirus is the most common cause of of atopic meningitis. The onset may be abrupt or gradual, and many of the presenting symptoms signs and symptoms are the same as bacterial meningitis, including headache, fever, photophobia, and nuchal rigidity. What's our nursing care? Again, it's very similar to our bacterial meningitis.

Keep the room as quiet as possible and environmental stimulate at a minimum as most children with meningitis are sensitive to noise, bright legs, and external stimuli. Also, keep the head of the bed elevated. Derivulocyst meningitis must be considered in children who have traveled to or lived in developing countries or who live with or are immigrants from developing countries. In 2015, the incidence of tuberculosis meningitis in the United States increased for the first time in more than 2 decades. Tuberculosis meningitis is most likely to be disseminated in very young or immunosuppressed children.

A ischemic infarction can occur with rurgulos meningitis. The most common clinical findings are meningeal signs, fever, altered consciousness, central nervous system involvement, seizures, and focal neurological deficit. Brain abscess. Intracerebral abscesses form when pyogenic organisms gain access to the neural tissue by the way of the bloodstream from foci of infection or direct inoculation of organisms from infections, penetrating trauma, or surgical procedures. Chronic ear infection, mastoiditis, sinusitis, and congenital heart disease are the most common predisposing factors for children with brain abscess.

The majority, about 70% of brain abscesses are caused by anaerobic or aerobic streptococci. In neonates, Citrobacter is the most common, and fungi are more common in immunosuppressed children. The most common sites of intracerebral abscesses are the peritoneal, temporal, and frontal lobes. Early signs of the disease are vague. However, the most common symptom is a severe headache.

Encephalitis is the inflammatory process of the central nervous system that is caused by a variety of organisms, including bacteria, fungi, protozoa, and viruses. Most infections are associated with viruses, and this discussion is limited to those agents. The clinical features of encephalitis are similar regardless of the agent involved. Manifestations can range from mild benign form that resembles aseptic meningitis, lasts a few days, and is followed by a rapid and complete recovery to a rapid progressing encephalitis with severe central nervous system involvement. The onset may be sudden or maybe gradual with malaise, fever, headache, dizziness, apathy, mucovrigidity, nausea and vomiting, ataxia, tremors, hyperactivity, and speech difficulties.

What's our therapeutic management? Patients affected of having encephalitis are hospitalized properly for observation, including intracranial pressure monitoring. In autoimmune encephalitis, rapid initiation of immunotherapy, including corticosteroids, osmophoresis, and IV immunoglobulin improves outcome. Herpes simplex virus encephalitis is the only viral encephalitis that has specific treatment available. Bradetes is an acute infection of the nervous system caused by a virus that's almost invariably fatal if left untreated.

It is transmitted to humans by the saliva of the infected mammal introduced through bitten or through a bite or skin abrasion. After entry into a new host, the virus multiplies its muscle cells and is spread through the neural pathways without stimulating a protective host immune response. Through dog vaccination, rabies from dog bites has been eliminated in the United States. Carnivorous wild animals such as raccoons, skunks, bat, and foxes are the animals most often infected with rabies and the cause of the most indigenous cases of human rabies in the United States. Educate about unusual behavior in the animal is cause for suspicion.

Children should be warned to be aware of wild animals that appear appear to be friendly. The current therapy for a rabid animal bite consists of 3 steps, thorough cleansing of the wound with soap and water, administration of rabies vaccine, and administration of rabies immunoglobulin. The rabies vaccine and immunoglobulin should be initiated as soon as possible after exposure. Reye's syndrome is a disorder defined as metabolic encephalopathy associated with other characteristic characteristic organ involvement. It is characterized by fever, profoundly impaired consciousness, and disordered somatic function.

The etiology of Reye's syndrome is not well understood for most cases follow a common viral illness, typically influenza or varicella. Reye's syndrome is a condition characterized by pathologically by cerebral edema and fatty changes in the liver. The onset of Ryerson is notable for perfuse, effortless, vomiting, and lethargy that quickly progress to neurological impairment, including delirium, seizures, and coma, and can ultimately lead to increased intracranial pressure, herniation, and death. The cause of Reye's syndrome is mitochondrial insult and induced by various viruses, drugs, exotoxins, and genetic factors. Elevated serum ammonia levels tend to correlate with the clinical manifestations and prognosis.

Definitive diagnosis is established by liver biopsy. The safety criteria for Reye's syndrome are based on liver dysfunction and on neurological signs that range from lethargy to coma. As a result of improved diagnostic techniques, children who in the past would have been diagnosed with Reye's syndrome are now diagnosed with other illnesses such as viral or inborn errors of metabolism, Causes of unrecognized drug induced encephalopathy by antiemetics given to children during viral illnesses have symptoms similar to those of Reye's syndrome. A potential associated between aspirin therapy for the treatment of fever in children with varicella or influenza and the development of Reye syndrome precludes its use in these patients. However, by the time the FDA required aspirin product laboring in 1986, most of the decline in Reye's syndrome incidents had already occurred.

Care and observation are implemented as for any child with an altered state of consciousness and increasing intracranial pressure. Accurate and frequent monitoring of intake and output is essential for adjusting fluid volumes to prevent both dehydration and cerebral edema. Because of the related liver dysfunction, monitoring lab studies to determine impaired coagulation, such as prolonged bleeding time. Keep the parents of the children with Reye's syndrome informed of the child's progress and explain diagnostic procedures and therapeutic management. Recovery from Reye's syndrome is rapid and usually without sequelae.

If the diagnosis is determined early and the therapy is initiated properly. Patients who survive have full liver function recovery. Seizures and epilepsy. Please view the video, that is in the module for more information on seizures. A seizure is a transient occurrence of signs and or symptoms due to abnormal excessive or synchronous neuronal activity in the brain.

The manifestation of seizure depends on the region of the brain in which they originate and may include unconscious or altered consciousness, involuntary movements, and changes in perception, behaviors, sensations, and or posture. Seizures are the symptom of underlying disease process. They are in individual events. Potential causes include infections, intracranial lesion or hemorrhage, metabolic disorders, trauma, brain malformations, genetic disorders, or toxic ingestion. The goal of treatment of a seizure disorder is to control the seizures or reduce the goal of treatment of a seizure disorder is to control the seizures or reduce their frequency and severity and discover and correct the cause whenever possible and help the child live as normal of a life as possible.

An important nursing responsibility is to observe the seizure episode and accurately document the events. Record any alterations in behavior preceding the seizure and the characteristics of the episode, such as sensory hallucination phenomena or aura, motor effects, eye movements, muscular contractions, or alterations in consciousness and post atrial state. The nurse should describe only what is observed rather than try to label a seizure type. Note that the time the seizure began and the duration of the seizure. Generalized seizures and other types with clear manifestations are easy to detect, but absent seizures may be more may present more difficulties.

They usually are misinterpreted as inattention. Any unusual behavior, even seemingly inconsequential, such as momentary interruption of activity, staring, or mental blankness, should be described. The more detailed these descriptions, the more valuable they are for assessment. And safety is a big concern for these patients as well. If a child is actively seizing, you would not move the child from the floor to the bed.

Headaches. Primary headaches are classified as migraine, tension type headaches, and other primary headache disorders. A migraine is one of the top 5 common childhood diseases. Migraines have can have their onset in very young children, including infants when they are when they manifest as colic. The onset tends to be earlier in boys than girls until puberty when girls have a twofold increase over boys and migraines.

This is thought to be due to the effects of estrogen. A secondary headache is caused from another condition and should be resolved once the underlying condition is treated. Headaches can be a result of conditions such as traumatic brain injury, brain tumor, brain infection, cerebrovascular disorders, withdrawal from or exposure to substances, vision problems, hunger, psychiatric disorders, and medication overuse. It is important to determine the headache the pattern of the headache, acute, acute recurrent, chronic progressive, or chronic nonprogressive. The assessment information includes the presence of seizures, ataxia, lethargy, weakness, nausea and vomiting, and or personality changes.

Factors related to early development and past illnesses and a family history of headaches may also be pertinent. A headache diary, which includes time and onset, determination of headaches, intensity, associated events, and actions taken, and their effort effects can be helpful for the patient and provider. If a child has a headache that wakes them up at night, they should be seen immediately. Hydrocephalus is a condition caused by imbalance in the production or absorption of the central spital fluid, or CSF, in the ventricular system. The cause of hydrocephalus are varied and include either congenital or acquired conditions The result is either impaired absorption of CSF fluid with the sub within the subarachnoid space, obliteration of the subarachnoid cisterns and malformation of the arachnoid villi, or obstruction to the flow of the CSF to the ventricular system.

Chiari 1 and Chiari 2 malformations are structural defects in the base of the skull on the cerebellum. They occur when the lower cerebellum extends below the boremum magnum and into the sup upper spinal canal, sherry 1. Over the lower cerebellum and the brain distributes into the spinal canal through the enlarged boremum magnum, maca, TRI 2. TRI malformation does not usually cause hydrocephalus. It is usually asymptomatic until adolescence when it can cause headaches, neck pain, frequent urination, and lower limb progressive spasticity.

Type 2 TRM malformation is seen almost exclusively with myelomeningocele and results in obstruction of the CSF flow causing hydrocephalus. So what's our therapeutic management? We want to treat the hydrocephalus as directed toward relief of the ventricular fracture, treatment of the cause of the ventricle magaly, treatment of associated complications, and management of problems related to the effect of the disorder on psychomotor development. The treatment with few exceptions is usually surgical. So improved neurosurgical techniques have established surgical treatment as the therapy of choice in almost all cases of hydrocephalus.

This is accomplished by direct removal of an obstruction, such as resect of a neoplasm, a cyst, or hematoma, or rare incidences of fluid overproduction. However, most children require a shunt procedure that provides primary drainage of the CSF from the ventriculars to an extracranial compartment, usually in the peritoneal. The singular procedure for many years has been a VP or ventral peritoneal shunt, especially in neonates and young infants. There is a greater allowance of excess tubing which minimizes the number of revisions needed as the child grows. Because it requires repeated lengthening, the ventral atrial shunt is reserved for older children who have attained most of their somatic growth and children who have children with cardiopulmonary disease or elevated CSF protein.

What are our complications? The major complications of a VP shunt are infection and malfunction. All shunts are subject to mechanical difficulties such as kinking, plugging, or separation in migration of tubing. Education for the family could include: to prepare the child for discharge at home care, instruct the parents on how to recognize signs and symptoms that indicate child malfunction or infection. Active children may have injuries such as fall that can damage the shunt, and the tubing may pull out of the distal insertion site or become disconnected during normal growth.

Contact sports such as football, rugby, boxing, and wrestling are prohibited if a person has a BP shunt. Other sports, such as swimming, soccer, and track, are usually acceptable and even encouraged for the child's physical and emotional health. Thank you for listening to this presentation on pediatric neurological conditions. Presentation on pediatric neurological conditions.

Transcript for:Overview of Pediatric Neurological Dysfunction

Transcript for:
Overview of Pediatric Neurological Dysfunction