Supplemental Neuro PP

Manifestations of Increased ICP Infants Children Bulging Fontanels Separated sutures High pitched cry Irritability, restlessness or Lethargy, indifference Distended scalp veins Change in feeding Inconsolability Change in LOC Headache Nausea/vomiting Diplopia Lethargy or irritability Seizures Increased sleep Inability to follow commands

Late signs of Increased ICP Lowered LOC Cushing’s reflex: Slowing of pulse 50’s-60’s Hypertension 155/50 Widened pulse pressure Alterations in pupil size and reactivity Decreased motor response Papilledema Cheyne-Strokes respirations Coma

Measurement of ICP: Pressure Monitoring Systems ICP monitoring is warrented in presence of increased ICP symptoms and/or when GCS eval is 8 or less Ventriculostomy with intraventicular catheter is the preferred method because CSF can be drained in a controlled manner by lowering or raising the collection device; but has higher infection rate. Monitoring devices often require site care similar to IV site care Subdural bolt: is stabilized with dressings which should not be removed or disturbed. In addtion to pressure monitoring the bolt can also be used to drain CSF fluid. Epidural sensor is the least invasive and has the advantage of reduced infection risk but does not always measure pressure reliably Subdural catheter if very similar to the epidural sensor Intraparenchymal catheters are indicated in cases of cerebral edema but have the highest infection rate.

External Ventricular Drain May be used if increased ICP and with hydrocephalus or if ventriculitis to drain infected CSF fluid; Level of drainage bag must be precise to avoid complications from lowing ICP too quickly

Pressure Monitoring Systems: Nursing Care Note: Type of catheter, Placement & Condition of dressing Maintain: HOB 10-30º per orders; Keep head midline No turning from side to side; May tilt/prop Site care for ventriculostomy is similar to IV site care Midline is to prevent compression of neck veins which could decrease venous return from brain increasing ICP

Neurological Disorders: Diagnostic Procedures CT scan MRI Lumbar Puncture (if no risk of Increased ICP!!) EEG Ventricular Tap (remove CSF and measure ICP) Subdural Tap (remove CSF and measure ICP) Nuclear Brain Scan RTUS (most useful for neonates with patent anterior fontanel) Many require sedation of child to obtain cooperation; common drugs are chloral hydrate and valium; prepare child based on developmental stage; emphasize most dx tests are painless; have parents assist or nearby; CT/MRI are most common for head injury; LP is done to r/o infection and assess for blood; EEG done to evaluate seizure activity or to document loss of brain wave activity; subdural tap is done with subdural bolt, Brain scan most often for tumor assessment;

Traumatic Brain Injury Primary injuries Concussion Fractures Contusions Intracranial bleeding Diffuse injury (diffuse axonal injury) Secondary complications Hypoxic brain damage (encephalopathy) Increased ICP Cerebral Edema Neurogenic shock Infection if penetrating wound and/or basilar FX Seizure disorder Hydrocephalus 3 major causes of brain injury in childhood are falls, MVA, and bicycle injuries; use of bicycle helmets can decrease brain injury by 88% Closed head injuries may be more dangerous than open injuries due to cerebral edema/intracranial bleeding with resultant increased ICP Severe diffuse axonal injury is often associated with severe encephalopathy with resultant persistent vegetative state

Brain Contusions Similar injury with MVA “whiplash”; accelerating/decelerating injury Symptoms can vary from mild concussion to diffuse, severe, trauma to brain tissue

Basilar Skull Fractures Raccoon eyes Basilar fractures—racoon eyes, brusing behind ear, blood from ears; No suctioning if basilar fx suspected. Monitor drainage from open wounds for amount and signs of infection Post-auricular ecchymosis: Battle’s Sign Rhinorrhea Otorrhea, hemotympanum

Concussion Most common head injury Defined as: Home care includes a transient and reversible neuronal dysfunction Hallmarks are confusion and amnesia Initial evaluation and monitoring in ER Home care includes Wake child q 2-4 hours to ascertain LOC Monitor for behavioral changes Call MD/Seek medical care if: Difficult or unable to arouse Increasing H/A, change in vision Vomiting > 3 times Onset of seizures Continued concussion symptoms after 48 hours Post concussion syndrome can occur in 30% of persons with significant concussion; headaches, blurred vision, vomiting, emotional lability, memory loss sleep disturbances can last 2-4 months Home care after initial evaluation; follow up appt 2 days later Signs of epidural hematoma may not develop till after 24 hours