Cerebral Injuries in Children Causes of Cerebral Injury: Head Injuries, Complications of Prematurity, Cerebral Infections, Near Drowning Etiology

y of Head Injuries o Infants Falls and Child Abuse o < 2 years-of-age Falls o Preschool/School Age Auto Accidents o lder Child/ Adolescent Accidents in!ol!ing "otor !ehicles# cycles and s$orts injuries %ales outnu"ber Fe"ales 2&' (e!els of Consciousness )( C* o Full Consciousness + A,a-e and Alert# riented to .i"e# Place and Person/ 0eha!ior a$$ro$riate for age o Confusion + I"$aired 1ecision %a-ing o Disorientation + Confusion re& .i"e and Place/ 1ecreased ( C o ethargy + (i"ited s$ontaneous "o!e"ent/ Sluggish s$eech o !btundation + Arousable ,ith sti"ulation o "tupor + 2e"ains in dee$ slee$# res$onsi!e only to !igorous and re$eated sti"ulation o Coma + 3o "otor or !erbal res$onse to no4ious )$ainful* sti"uli o Persistent #egetati$e "tate %P#"& + Per"anently lost function of the cerebral corte4/ Eyes follo, objects only ,hen by refle4 or ,hen attracted to the direction by loud sounds/ All 5 e4tre"ities are s$astic but can ,ithdra, fro" $ainful sti"uli/ Hands sho, refle4i!e gras$ing and gro$ing/ Face can gri"ace# so"e food "ay be s,allo,ed and the child "ay groan or cry but utter no ,ords Assess"ent o Physical E4a" + 0rief but .horough o A0C6s o 7ital Signs o Pu$il Chec- - fi4ed/dilated/blo,n 80A19 o Focal Findings o :lasgo, Co"a Scale - eye/"otor/!erbal Patho$hysiology o Pathology is directly related to force of i"$act o Pri"ary !s Secondary o Pri"ary + ccur at ti"e of trau"a S-ull injuries Contusion Intracranial he"ato"as 1iffuse injuries o Secondary + ;hat occurs because of the trau"a Hy$o4ic 0rain 1a"age Increased ICP Infection Cerebral Ede"a Concussion o 3eurological %anifestations I"$aired consciousness for a !ariable $eriod of ti"e

Headache )Post Concussion Syndro"e* 7ertigo 1e$ressed 2efle4es An4iety :eneral %alaise o 2es$iratory %anifestations 1ecreased 2es$irations o Cardio!ascular %anifestations 0radycardia Hy$otension Postconcussion Syndro"e o Sy"$to" co"$le4 that "ay occur ,ithin days of the injury and can include& Headaches 1i<<iness Fatigue Irritabilty An4iety Inso"nia (oss of Concentration %e"ory I"$air"ent Parents "ay say they are really crabby# not the"sel!es after a cou$le of days o Clinical sy"$to"s of the follo,ing are all closely associated ,ith Postconcussion Syndro"e - See Critical .hin-ing E4ercise on Page '=2>& (oss of Consciousness Posttrau"atic A"nesia :CS Score < '= 1isorientation ther %ental Status changes Contusion and (aceration o 3eurological %anifestations Possible loss of consciousness %ild "otor or sensory ,ea-ness Headache 7ertigo Post-.rau"atic Sei<ures Co"a Irritability 2estlessness Fractures o (inear o 1e$ressed o Co"$ound o 0asilar

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Diastatic Neurological Manifestations Altered skull contour Conjuctival Hemorrhage associated with fracture of the anterior fossa CSF hinorrhea !

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"erior#ital $cch%mosis CSF &torrhea "alsies of C1' C( and C) nerves "ost*traumatic Sei+ures ,ate Sign Coma

Cardio!ascular %anifestations o Hy$o!ole"ia + Associated ,ith fractures o!er the lateral or sagittal sinus Integu"entary %anifestations o Ecchy"osis at the base of the nec- + Associated ,ith basilar s-ull fracture and fractures o!er the "astoid $rocess Co"$lications of Head Injuries E$idural He"ato"as Subdural He"ato"as Subarachnoid he"orrhage Intracerebral He"orrhage Cerebral Ede"a Posttrau"atic Syndro"e Sei<ures

E$idural He"ato"a 3eurological %anifestations + .he classic $icture of an E$idural he"ato"a is& o %o"entary ?nconsciousness + Follo,ed by a nor"al $eriod for se!eral hours# then lethargy or co"a due to blood accu"ulation in the e$idural s$ace/ .he lethargy and co"a are due to blood accu"ulation in the e$idural s$ace and co"$ression of the brain Cushing .riad is a late sign of i"$ending brain herniation 2es$iratory %anifestations o 2es$iratory 1e$ression o A$nea Cardio!ascular %anifestations o 0radycardia :astrointestinal %anifestations o 7o"iting As the e$idural He"ato"a increases the dura is stri$$ed fro" the s-ull + this leads to forcing the underlying brain contents do,n,ard and in,ard as it e4$ands/ Causes res$iratory issues E$idural He"ato"as occur infre@uently in infants and children but ,hen they do they are usually caused by Child Abuse )Sha-en 0aby Syndro"e* in the infant and child and %otor 7ehicle Accidents )%7A6s* in the adolescent o ?sually arterial in origin ,hich leads to ra$id brain deco"$ression

Subdural He"ato"as A A Subdural he"ato"a is bleeding bet,een the dura and the arachnoid "e"brane %uch "ore co""on than e$idural he"ato"as in children ,ith $ea- incidence at B "onths of age )due to child abuse/falls*/ 3eurological %anifestations + ?sually $resent ,ith diffuse sy"$to"s o Headache o (oss of Consciousness o Focal Sei<ures o ?nilateral Pu$illary 1ilatation - needs to re$orted i""ediately/ need to alle!iate $ressure other,ise herniate and die/ sit the" u$ to chec- $u$ils/ o He"i$aresis o Agitation o 1ro,siness ,ith Confusion o Progressi!e Slo,ness of .hin-ing 3ursing 1iagnoses Associated ,ith Cerebral Injury in Children Ineffecti$e breathing pattern %with potential for respiratory failure& related to C ICP/ 3eed to suction///"a-e sure it is effecti!e/ 'DDE 2/ Altered Peri$heral $erfusion 2/. Hy$otension Secondary to Hy$o!ole"ic Shoc-/ 0leeding in head so blood in rest of organs not as ade@uate/ High 2is- for Fluid 7olu"e 1eficit 2/. 3ausea and 7o"iting/ ;ant to sto$ !o"iting because of increase in ICP/ ?se Fofran9 1ecreased C/ / related to he"orrhage High ris' for injury ()* to +ltered !C secondary to head injury or increased ICP or both High (is' for injury secondary to sei,ures o Call for help o Put them on side)unrestrain them o +irway)safety is your priority Pain related to head injury - bring them out of opiod sedation to do assessment. +n/iety %Child and Parent& related to traumatic head Injury High ris' for infection ()* Injury High ris' for impaired s'in integrity ()* physical immobility 0nowledge deficit ()* home care Case G ' H/%/ is a 2 "onth-old infant girl ,ho $resented to the E"ergency 1e$art"ent )E/1/* lethargic# hy$otonic and bradycardic and ,ith a bulging anterior fontanel/ Her 'I year old "other stated that H/%/ fell out of her baby s,ing onto a car$eted floor 2 days ago/ Four hours after ad"ission# H/%/ begins to sei<e continuously )status e$ile$ticus* and re@uired endotracheal intubation/ A C/./ Scan re!eals bilateral subdural he"ato"as o 2ed Flags& H4/injury are not consistent/ Certainly canJt be bilateral/ %ost li-ely sha-en baby syndro"e/ ;hat is the "ost li-ely etiology of this child6s injuryK o Sha-en 0aby Syndro"e Complications of Prematurity - Not going to tal' about this... Perinatal Hy$o4ic-Ische"ic 0rain Injury o Hy$o4ic-Ische"ic Ence$halo$athy is the resultant cellular da"age fro" hy$o4ic-ische"ic injury o .he site of the injury ,ill de$end on the neonates gestational age In the ter" infant the $ri"ary site of injury is the $arasagittal cerebral injury cortical necrosis )dee$er $ortion of the brain* /In the $re"ature infant the $ri"ary ische"ic lesion is in the ,hite "atter near the !entricles or $eri!entricular ,ith resultant $eri!entricular leu-o$lacia C3S

Intra!entricular )I7H* - $eri!entricular he"orrhage )P7H* %ost co""on brain injury in $re"ature L =DE of those ,ho die in first fe, days of life ha!e he"orrhage Etiol/ - 0P fluctuations# "echanical !entilation# as$hy4ia# ra$id infusion of !olu"e# 3aHC M# or hy$eros"olar solutions# coagulo$athy# $neu"othora4

0leeding occurs in sube$endy"al ger"inal "atri4/ :rade I I7H- sube$endy"al he"orrhage in $eri!entricular ger"inal "atri4# locali<ed at the fora"en of %onro :rade 2 I7H + $artial filling of lateral !entricles ,ithout !entricular dilatation/ :rade M I7H + I7H ,ith !entricular dilatation :rade 5 I7H - can be s"all or !ery large/ 0leeding into brain $arenchy"a

Al"ost >DE of bleeds occur in first fe, days of life S L S - sudden deterioration# bradycardia# acidosis# fall in H/H# shoc-# hy$erglyce"ia# tense anterior fontanel/ r S L S "ay be gradual (ate - tense# bulging fontanelles# increasing !entilatory su$$ort# sei<ures# a$nea# co"a .reat"ent I7H .reat"ent + $re!enti!e# su$$orti!e# =DE of acute# se!ere I7H infants die/ I7H "aybe self-resol!ing %ay resol!e ,ith "ini"al disability %ay re@uire $lace"ent of an intra!entricular shunt ,ith or ,ithout neurode!elo$"ental disability/ Sei<ures + .reated ,ith Phenobarbital# Fos$hyntoin Infection of shunt + "eningitis increases ris- for abnor"al neurode!elo$"ental disabilities Cerebral Infections Ence$halitis + ccurs as a result of )'* direct in!asion of the C3S by a !irus or )2* $ostinfectious in!ol!e"ent of the C3S after a !iral illness o S$ecific ty$e of ence$halitis "ay not be identified o .he "ajority of cases in children are associated ,ith "easles# "u"$s# !aricella and rubella/ (ess co""on causes are entero!iruses# her$es !iruses and ;est 3ile 7irus o Her$es Ence$halitis is not co""on but MDE of the cases re$orted in!ol!e children Clinical %anifestations o Can range fro" "ild )sa"e as ,ith ase$tic "eningitis* to ful"inating ence$halitis ,ith se!ere C3S in!ol!e"ent o Sudden or gradual onset of sy"$to"s

Se!ere Cases High Fe!er Stu$or Sei<ures 1isorientation S$asticity Co"a + that "ay $roceed to death cular $alsies and $aralysis 1iagnostic E!aluation o Clinical findings and identification of the s$ecific !irus o C/./ Scan "ay be nor"al initially + (ater he"orrhagic areas in the frontote"$oral region "ay be seen o 3ot all !iruses ,ill be found in the CFS + Her$es# entero!irus# "u"$s# "easles and !aricella are found in the CFS .hera$eutic %anage"ent o Pri"arily Su$$orti!e Conscientious 3ursing Care Control of Cerebral %anifestations Ade@uate 3utrition and Hydration Sub"ersion Injury %ajor cause of unintentional injury-related death in children ages '-'5 years/ %ost organ syste"s ,ill be affected/ All children ,ho ha!e a sub"ersion injury should be ad"itted for obser!ation + sy"$to"s "ay not occur for 25 hours/ Proble"s seen in sub"ersion injuries o Hy$o4ia and as$hy4iation - highest $riority o As$iration o Hy$other"ia Case Study - Car Accident ;hat ,ere the Priority 3ursing Inter!entions based on the Priority 3ursing 1iagnoses for Andre, u$on arri!al in the PIC?K 3euro/res$iratory assess"ents are $riorities9 o I"$aired :as E4change o Ineffecti!e Cerebral .issue o 1ecreased Intracranial Ada$ti!e Ca$acity o 2is- for injury# sei<ures ;hat is the "eaning and significance of Andre,6s :lasgo, Co"a Scale u$on ad"ission to the PIC?K 1iscuss his current Score/ 'D out of '= :CS/ Incontinent of urine/stool/ Cough is "ore effecti!e/ ;hy does Andre, ha!e a tracheosto"yK Can $ossibly as$irate secretions/ 3eed to suction to $re!ent infections/ Still needs hu"idification because it by$asses natural hu"idification of u$$er air,ay/ 1onJt ,ant it $lugging/ ;hy does he recei!e g-tube feedingsK 0ecause of $otential of as$iration fro" suc-/s,allo, is di"inished/ ;hat are the nursing $riorities for the student nurse assigned to Andre,K .rach care# neuro chec-s# res$iratory# s-in care# nutrition/calories for healing# F/E# I/ # su$$orting $arents to decrease an4iety/ ;hy is it i"$ortant that Andre, recei!e 2 % e4ercisesK 1ecreases long ter" issues secondary to i""obility li-e "uscle atro$hy/ ;or- ,ith ./P./S$eech/2./1iet/Child (ife/neuro/ortho/ ;hat are the $riority concerns about Andre,6s bo,el and urinary incontinenceK S-in brea-do,n infection/ ;hat thera$eutic a$$roaches should the nurses use ,ith Andre,6s "o"K thera$eutic co""unication - not "o"Js fault/ ;hat other health $rofessionals should be included in Andre,6s careK Financial issues# then social ,or-/ o D22I2D'5

Palliati!e Care %o!ie