(506) Neurological Alterations

You are examining a 6-month-old infant who "fell off the bed" onto a carpeted floor. The mother, who witnessed the incident, stated the infant cried immediately. The CT shows a depressed skull fracture and multiple subdural hematomas at various stages of healing. What should you consider?

"The infant cried immediately." This is important assessment data that tells us that infant did not lose consciousness and was responsive when they fell Multiple subdural hematomas at various stages of healing - tells us we have multiple bleeds pf different ages (may have happened in past?) Depressed skull fracture - type of injury you would expect to see in a 6 month old, because there skull is mostly cartilage (soft bone), so they are not likely to have a linear skull fracture Degree of injury doesn't match the mechanism of injury 6 month is peak age where subdural hematomas happen the most often. Abuse (nonaccidental trauma) is possible, so we must ask more questions, but it is also possible that the child could get a fracture from a fall onto the floor. T he child could have legitimate non-abuse reasons for these injuries. Therefore, we must be very comprehensive in our assessments and keep our minds open to different possibilities

Frontal lobe

*Motor and speech area of Broca is the part of the brain that controls important cognitive skills in humans, such as emotional expression, problem solving, memory, language, judgment, and sexual behaviors. It is, in essence, the "control panel" of our personality and our ability to communicate. A region of the cerebral cortex that has specialized areas for movement, abstract thinking, planning, memory, and judgement

parietal lobe

*Reading comprehension area It processes sensory information it receives from the outside world, mainly relating to touch, taste, and temperature. Damage to the parietal lobe may lead to dysfunction in the senses A region of the cerebral cortex whose functions include processing information about touch.

Linear Skull Fracture

--One of the skull bones breaks in a line --Most common fracture --Rare before 2 years of age, because prior to that time, the child's skull is mostly cartilage

Potential Complications of Increased ICP

-Brain tissue death -Diabetes insipidus -Syndrome of inappropriate ADH -Pulmonary Edema -GI bleeding -DIC -Secondary Brain Injury (reperfusion injury) *Increased ICP and the damage caused by it can cause multisystem body issues, just like sepsis

Key Points of Maintaining Adequate CPP

Decrease metabolic needs of brain -Sedation/paralysis -Maintain normothermia or mild hypothermia (NO FEVER OR SHIVERING) -Prevent seizures Send the right amount of blood up -Not too much (Mild hyperventilation) -Not too little (Don't overdo the hyperventilation) -Avoid hypotension (goal may be HYPERtension) Send only the "good stuff" up -Oxygen is good! -Maintain euglycemia

Clinical Presentation of increased ICP

-CHANGES IN BEHAVIOR, LOC, OR RESPONSE TO PAIN -Bulging fontanel, separated sutures, increased head circumference, dilated scalp veins (INFANT) -Headache, diplopia, blurry vision (OLDER CHILDREN) -Unequal, dilated, sluggish/fixed pupils "sun-setting eyes," or papilledema -Feeding intolerance, projectile vomiting (especially vomiting without nausea) -Sensory/motor deficits -Seizures -Cushing's Triad: Hypertension, bradycardia, widened pulse pressure (also apnea) -Posturing (decorticate, decerebrete) *Increased ICP presents with a wide variety of signs and symptoms. The clinical presentation depends a lot on the patient's age Important: In all patients the FIRST sign of changes in ICP are you will see CHANGES IN BEHAVIOR, LOC, OR RESPONSE TO PAIN In infants, you may have a vague feeding intolerance. They may not latch well, no interested in eating, have very disorganized suck, and they may projectile vomit. If a child projectile vomits without feeling nauseous, that can be a very concerning sign Any change in sensory or motor performance Seizures, especially if new onset

cerebrospinal fluid (CSF)

-Clear and odorless -Glucose: 60% of serum glucose -Protein: 15-45 mg/dL -Usually no RBC/WBC -Opening pressure 5-20 cm H2O (age dependent) -Infants produce 1 mL/hour -Adults produce 30 mL/hour -Infant total volume 50 mL -Adult total volume 150 mL *In a healthy person, it should be clear and odorless There is glucose within CSF, it is generally about 60% of what the person's serum glucose is. To compare it, you'd have to know the glucose level of the CSF while simultaneously checking a serum glucose. 60% is an estimate, but if you have glucose levels in CSF that are substantially higher or lower than expected, this may give you some clues to what underlying pathology may be. The amounts of protein in CSF is variable and dependent on age, infants have much higher protein levels than adults Usually no RBC/WBC within healthy CSF. If you do have WBCs, that can be a clue there is an infectious process. Small amounts of RBC in sample is usually operative error (trauma to blood vessels from procedure) One of the things that is done when doing a spinal tab or lumbar puncture is to measure the pressure of the CSF. The term used is "opening pressure", because it is the pressure within that space when it is first accessed. It is generally 5-20 cm H2O, but this is age and position dependent. If someone is sitting upright and the pressure is being measured at the lower part of the spine, the pressure will be much higher than if that same patient is lying down due to gravity The body is constantly producing CSF, circulating CSF, and reabsorbing CSF. Anytime you have an interruption in one of those processes, you will have changes in pressure There is a large disparity between the infant volume of CSF and the adult volume of CSF. This is important, because if you are withdrawing CSF to send for a sample, you have to think about proportionately how much more CSF that is for an infant/child compared to an adult. Younger children and infants will be more symptomatic after a sample of CSF is drawn than an adult would be

Nursing implications for lumbar puncture

-Consent -Pain management -Safe positioning -Patient monitoring -Specimen labeling -Keep flat -Monitor site *Some of the considerations are that this is an invasive procedure, so it requires informed consent. The provider doing the procedure will obtain the informed consent, but as the nurse, you may witness that the consent was actually signed by the patient. The nurse will also ensure the patient has adequate knowledge about the risk, benefits, and alternatives Also consider pain management - For a cooperative adult, often it is just a local injection that is administered prior to the needle insertion. Younger children do not hold still as well, so we may need to do more aggressive IV sedation prior to the procedure Safe positioning of patient - an adult will often sit upright and lean forward to pull the spinous processes apart. Young children, it is much easier to have them lye on their side with their knees touching their chin (this position will do the same thing; round the spine out, so the processes pull apart and it is easier to access the space). Infants will use the safe position, and the nurse is often the one who will have to position the infant ("ball up" infant with them lying on their side) Keep in mind, especially if the child is sedated, you need to maintain their airway as well. if you ball them up too tightly, you will cut of their airway. Position them while maintaining airway and having appropriate monitoring on patient When the spinal fluid is withdrawn, it will be filled into multiple separate tubes. The order of the tubes is actually incredibly important, because the culture has to go first and the cell count has to go last. Make sure those specimens are labeled appropriately with the right order. The patient needs to remain flat. The hole from the needle will seal spontaneously, so these patients will need to stay flat and immobile for usually an hour or two Many patients will also develop a headache afterward, because of the shift in intracranial dynamics. Doing slow position changes and remaining flat usually helps that equalibrium Then you want to monitor sight. If it starts leaking CSF, that is a concern, because if CSF can leak out, microorganism now have a tract to go in, which can result in meningitis

Monro-Kellie Doctrine:

-Cranium is a fixed space: A change in one of the contents requires compensation by the other contents -When compensation fails, ICP increases dramatically, resulting in herniation *ICP is based on the Monroe-Kellie Doctrine, and that is that the cranium or the skull is a fixed space, so when you have a change in one of the contents in the pressure that is exerting, it requires compensation by the other contents or else your ICP will go up Once these compensatory mechanisms fail, you'll then have a dramatic increase in ICP and that will eventually result in herniation. Doesn't apply to infants, because infants do not have a fixed cranium. They have the fontanels and open sutures, so their skull is actually able to increase in size as the pressure within the brain increases. This is why head circumferences are such an important assessment finding in children with open sutures and fontanels, because they will not show the signs of increased ICP. There head will just get big first!

The brain requires constant supply of oxygen and glucose

-Cytotoxic cerebral edema within seconds of anoxia (Hypoxic-Ischemic Encephalopathy) -Kids tolerate hypoglycemia poorly anyway -Seizures can result from hypoxia and/or hypoglycemia *Within seconds of having a hypoxic event, you start seeing these cellular changes of cytotoxic cerebral edema Hypoxic ischemic encephalopathy (HIE) is the term used in the NICU for babies who have had a hypoxic event either in utero, during delivery, or in the immediate post-natal period (within seconds, you start to see cellular changes) Glucose levels are important, and they are particularly important in children, because young kids tolerate hypoglycemia poorly anyway. Unlike an older child or an adult, young kids/infants are not able to do glyconeogenesis and produce their own glucose, so when they are put under stress or are ill, they will burn through their glucose stores and become profoundly hypoglycemic very quickly No matter the age, seizures can result from a hypoxic event or hypoglycemia, which will further increase the metabolic needs of the brain

Meninges of the brain

-Dura mater -Arachnoid -Pia mater *Depending on where a bleed occurs will be the name of the bleed For example, if it is below the arachnoid layer, it will be a subarachnoid bleed

Miscellaneous

-Edema -Intracerebral bleed -Subarachnoid bleed -Intraventricular bleed

Common Culprits of Viral Meningitis

-Enterovirus -Arbovirus -Herpes virus

Kernig's sign

When the patient is lying supine, you raise up one of their legs and straighten the leg. at the knee. This will cause menigeal irritation, so it will cause the patient pretty significant pain *a diagnostic sign for meningitis marked by the person's inability to extend the leg completely when the thigh is flexed upon the abdomen and the person is sitting or lying down

Anatomy of the brain

When we talk about patients who have a head injury (trauma, stroke, hemorrhage, etc), when you understand where the injury is occurring, you can reasonably predict what functions the patient may have difficulty with. Is it going to be movement, speech, thought processing?

Create low-stimulation environment (Manipulating ICP)

-Environmental factors (light, noise, touch) -Sedation *Clustering care is good, but not if it makes their ICP go up too high. Delicate balance of what is less distressing to the patient; doing several things at once or do I need to do one thing, then give the patient a break before I do another thing Having family present is often very helpful for the patient, but if the family member is overstimulating the patient (touching them too much, constantly playing with their hair, moving their extremities), this could increase ICP. Therefore, the nurse should teach the family safe ways to touch the patient that are comforting without being overstimulating The use of IV sedation: -You will often see a mixture of opioids and benzos to maintain sedation

Infants - Clinical Presentation, increased ICP

-Full or bulging fontanels, -The sutures in between the skull bones with be separates (fault lines will get bigger), and you can actually feel that with your fingers, -Increased head circumference. -Especially in young infants, you will see dilated scalp veins (because of increased venous pressure)

Promote cerebral drainage (Manipulating ICP)

-Head of bed elevated at least 30 degrees -Head midline -Avoid sharp hip bends -Avoid high ventilator pressures and gastric distention *Taking care of patients with increased ICP is very nursing driven. Every nursing action you do has an impact on the patient Promoting cerebral drainage is important, because blood gets up to the brain, but it has to also get out and not trapped: -Head of bed elevated at least 30 degrees -Head midline. If the patient's head gets turned, it will occlude the jugular vein on that side, and you will see their ICP increase immediately if they have a monitor in place -Avoid sharp hip bends. We want the head of the bed elevated, but not so high that they are putting pressure on their abdomen with their thighs, which will impede venous blood flow -Avoid high ventilator pressures and gastric distention, because that will put pressure in there chest cavity, which will impede venous return from the head

Neurological Exam Components

-Health history -Observation -Glasglow Coma Scale (LOC) ---Eye opening ---Verbal response ---Motor response -Vital signs -Physical exam -Cranial nerves -Reflexes/Cerebellar fxn -Labs -Diagnostic studies

Cerebral blood vessels will auto-regulate to maintain adequate supply

-Hypertension causes cerebral artery constriction -Hypotension causes cerebral arterial dilation -Hypoxia causes cerebral arterial dilation -Hypercarbia causes cerebral arterial dilation *The brain is supplied by the carotid arteries. The carotid arteries will expand and restrict to meet the needs of the brain Blood supply to brain must equal demand of brain Again, these cerebral vessels will auto-regulate to ensure that the brain receives an adequate supply of blood and oxygen, so when you have changes in the physiology, the vessels will respond accordingly -For example, if a patient is hypertensive, the cerebral arteries will constrict to minimize the amount of elevated BP that the brain is exposed to -In contrast, when a patient is hypotensive, those same vessels will dilate to allow more blood flow to the brain (to maintain supply of O2 and glucose) -if we switch to a respiration perspective. When a patient is hypoxic, the cerebral arteries will dilate to allow more blood volume, which will bring a greater oxygen supply to the brain -If a patient is hypercarbic, those cerebral blood vessels will also dilate in order to wash out that accumulated CO2 These principles become very important when we talk about nursing management of a patient with neurological alteration, because we are going to capitalize on these normal physiological responses to maintain the patient

Depressed Skull Fracture

-More common than linear fracture in children <2 -Malleable bone becomes dented

Send the right amount of blood up

-Not too much (Mild hyperventilation) -Not too little (Don't overdo the hyperventilation) -Avoid hypotension (goal may be HYPERtension) *You want to make sure you are sending the right amount of blood up to the brain. This goes back to the cerebral blood vessels constricting and expanding based on the needs of the brain You want to make sure you are not sending too much blood volume up, because now you have more blood within the skull, which will increase the amount of pressure. If we hyperventilate the patient (breathing faster, we can do this when they are mechanically ventilated), they will blow off more CO2, so they will have a lower PaCO2, and those cerebral blood vessels will constrict. Basically, if we keep the patient slightly hypocarbic, we will limit how much blood volume goes to the brain The flip side is, we still need blood volume to go to the brain, so we don't want to hyper ventilate them too much, because if those vessels get too constricted, now we are not providing sufficient oxygen or glucose Avoid hypotension, because if the patient is hypotensive, they will not have adequate blood flow to the brain. Depending on what the intracranial pressure is, you may need to make the patient hypertensive in order to compensate for the increased ICP that is preventing blood flow

Send only the "good stuff" up

-Oxygen is good! -Maintain euglycemia *The blood that you do send to the brain should be of high oxygen content and a healthy glucose level

Nursing Implications

-Safety -Know how to use marking system

Decrease metabolic needs of brain

-Sedation/paralysis -Maintain normothermia or mild hypothermia (NO FEVER OR SHIVERING) -Prevent seizures *If you set your bar lower, it is easier to achieve. Some things that can be done include the use of sedation or chemical paralysis for the patient. Again, if you make the patient essentially unconscious, the metabolic demand of there brain will be much lower than someone who is alert and interactive Another strategy is to maintain a normal body temperature or even slightly cold. Do not let the patient get febrile and you do not want to induce a fever shivering, because that increases metabolic demand substantially Prevent seizures, perhaps even using antiepileptics in a patient who does not have a seizure history

Types of Head Injuries

-Skull fractures -Concussion -Contusion -Subdural hematoma -Epidural hematoma

Common culprits of Bacterial Meningitis in children

-Streptococcus pneumoniae (pneumococcal) -Neisseria meningitidis (meningococcal) -Haemophillus influenzae type B (Hib) -Neonatal menigiitis: E. Coli and GBS *Three out of the four we now vaccinate against, the fourth one the causes are all sourced from mom. E. coli is the most common cause of UTIs in pregnant women, which is why we are so aggressive at treating UTI symptoms in pregnant women. Group B Strep is why all pregnant women get swapped the month before delivery so antibiotics can be administered before delivery

Cranial Nerves/Reflexes/Cerebellar Function

-Test for symmetry -Challenges: age and clinical condition *Remember when you are doing cranial nerves and reflexes, you always want to check for symmetry. Response on the right side of body should be the same response you get one left The challenges of doing cranial nerves and reflexes are related to age and clinical condition. Most of those cranial reflexes, and to do cerebellar function you need to give directions to your patient and the patient needed to follow instructions. If you have a very young child, they may not be able to do those things. Think creatively, how can you elicit that same response? A patient may not be able to follow instruction of "Can you cough for me?," but could you stimulate the back of their throat with a suction catheter, which will basically elicit a cough (Cranial nerve 10, vagus nerve), then you can evaluate that cranial nerve. Same thing with clinical condition, in a patient who is very sick or is receiving some sort of sedating medication, they may not be able to follow those instructions. Again, what can you elicit even if they cannot follow directions

Basilar Skull Fracture

-This is along the base of the skull (nape of neck) -Very serious; can damage underlying structures -Risk for CSF leak/Meningitis *These are very serious fractures, because at the base of the neck there are a lot of small bones that will break off into tiny fragments. Those tiny bone fragments can cause a lot of damage to the underlying structures, such as the brain stem and the cerebellum. These types of skull fractures are at the highest risk for developing a CSF leak and meningitis (bone fragments ripping through meningeal layers). Anytime you have a CSF leaks, if CSF can leak out, microorganisms can get in, putting the patient at risk for meningitis

On exam for increased ICP, you will see

-Unequal, dilated, sluggish, or fixed pupils -"Sun-setting eyes," where they look like they are opening their eyes very wide, but the actually are not. The pressure on the head is actually pushing down on the orbits, so it is rolling the eyeball forward, so you can see more of the sclera along the top edge than you normally can (iris becomes pushed down, looks like setting sun) -Papilledema, which is seen on an eye exam. It is looking at dilated or ruptured blood vessels within the eyes

Subdural Hematoma

-Venous bleed between dura and cerebrum -Tends to develops slowly, because it is a venous bleed -Peak incidence of spontaneous subdural hematomas at 6 months of age. This has to due with how cerebral blood vessels develop

Arachnoid

-Web-like structure covers brain loosely -Subarachnoid space (between arachnoid and pia) contains CSF

Cerebellum

A large structure of the hindbrain that controls fine motor skills.

temporal lobe

A region of the cerebral cortex responsible for hearing and language.

Meningitis

Acute inflammation of the meninges -Primary disease or secondary infection -Bacterial or viral (occasionally fungal in someone who is immune compromised) -Most common in ages 1 month to 5 years *Someone can get meningitis or it could develop as a complication, for example, after a lumbar puncture or having a drain in place

Concussion Nursing Priorities

Airway - Breathing - Circulation - Disability Most mild/moderate concussion can be managed at home Teach family to do Q2 neuro checks for 1-2 days post-injury to ensure nothing progresses and gets worse (Need to actually wake them up; Do you know where you are? Are you having double vision? Do you feel like you are going to vomit). If anything changes, seek emergency care again Teach family it is essential to avoid another injury during healing process. Brain is very friable during recovery time/healing process --Return to play/Return to school guidelines ---Cognitive rest ---Gradual resumption of physical activity, monitoring for symptoms "Post-concussion syndrome" Links with epilepsy and Alzheimer's *Return to play/Return to school guideline. ---Most guideline advise a stepwise approach. If the child is at home for two weeks and then slowly phasing back into a partial day at school and as long as they remain asymptomatic (not having changes in level of consciousness, not getting headaches, not getting dizzy, not getting visual changes, not vomiting), then they can progress to full days ---Gradual resumption of physical and cognitive activity and monitoring for symptoms. If the patient develops symptoms, it is important to backtrack ---Need to go slow and steady, because even a minor injury after a concussion can have serious consequences Especially with repeated concussions, but also with singular concussions, there is this phenomenon called, "Post-concussion syndrome" where the symptoms can persist even months after the injury has resolved. Teach families about the potential for this. Especially in the sport world, they have looked at the long term effects of repeated concussions. There are some suggestive links between repeated concussions and the development of epilepsy and Alzheimer's

Viral Meningitis

Also referred to "Aseptic meningitis" Peak in summer and fall Usually milder illness of 1-2 weeks duration Treatment is mostly supportive; Occasional antivirals *Antiviral are only used in highest risk patients, because they do not work very well and they come with a lot of side effects (risk/benefit analysis) Young children can get hospitalized for viral meningitis, because when they have a fever, they they don't eat or drink. Therefore, they become dehydrated. In this case, they simply need aggressive fever management, IV nutrition, and hydration (It will take 1-2 weeks for them to recover) It is not that we are treating the meningitis, we are more supporting the patient through the illness

Diabetes Insipidus and Syndrome of Inappropriate ADH (Potential Complications of Increased ICP)

Are both a problem, and they can coexist within the same patient As the pressure is put on the pituitary gland and you have changes in ADH released, you may have a patient who is in DI, then all of a sudden 30 minutes later now they are in SIADH The treatment of those two problems is the complete opposite, so one of your nursing roles is really keeping tabs on what state the patient is in and how do you manage them

Cushing's Triad

As ICP continues to increase and herniation is imminent, you will see something called Cushing's Triad You will see: -Profound HTN -Reflex Bradycardia -Widened Pulse Pressure (could also be apnea)

Basilar Skull Fractures - Example Findings

Battle Signs Raccoon Eyes *Result of damage that occurs to the blood vessels in that area

increased ICP

With all intracranial alterations, the problem is ____ ____, so all the management principles will be done

CT Scan

Best for bone, bleed, abscess, ventricular size (bone, blood, pus, contrast show up white) Can also do 3D bone reconstruction Pros: Quick, can be with or without contrast (IV and/or PO), less expensive Cons: Radiation, not as detailed, iodine contrast allergy, need good IV for contrast, PO contrast = yuck! *CT scan is x-ray exposure, so especially with younger children, we want to limit how much radiation exposure they have to their brain That being said, CT scans tend to be very quick, so they are the preferred initial radiology scan for a patient who presents with acute neurological changes A CT scan can be done with contrast. It might be oral contrast or it might be IV contrast, so you need to plan ahead about having appropriate IV access. The contrast is not given by a human being, it is given by an automatic injector that synchronizes the timing of the contrast with the timing the images are taken. It is very precise, and it needs to be a fairly large IV

MRI

Best for tumor and tissue detail (low-fluid volume shows up dark) Pro: Much more detailed, no radiation, can view in multiple planes, can be with or without contrast Con: Lengthy, expensive, claustrophobia, noisy, metal contraindications, gadolinium contrast allergy, may need IV and sedation *MRI uses magnets, so no radiation exposure. With that being said, it also takes a lot longer, it is more expensive, concerns about claustrophobia for the patient Because it is a magnet, you need to be very careful about metal screening. Does the patient have any sort of metal within their body? Either from a device, an injury, or a tattoo. What type of equipment do they have? The patient needs to have all MRI compatible equipment.

raccoon eyes

Bruising or ecchymosis around the eyes, indicative of a basilar skull fracture Do not develop immediately. It will always look worse on subsequent day Important teaching point for families; you may start seeing bruising on first day, but the next day it will look way worse

Battle sign

Bruising or ecchymosis behind an ear over the mastoid process that may indicate a skull fracture.

Management of Increased ICP

CPP = MAP - ICP CPP; cerebral perfusion pressure --Net blood flow to brain MAP: mean arterial blood pressure --Amount of flow pushing "up" to perfuse the brain ICP: intracranial pressure --Amount of flow pushing "down" (fighting against the MAP) Goal is to maintain adequate CPP for brain perfusion *When we manage patients that have increased ICP, regardless of the cause, it is all going to be based on this top formula MAP is pushing up to perfuse the brain ICP is pushing down, and the net result is CPP What you are trying to do by your various interventions is to maintain adequate CPP to meet the brain metabolic demand

CT vs MRI

CT -Can see gyri in cerebrum, ventricles MRI -Detail much greater -Can see pons, cerebellum Depending on the reason for doing the particular type of scan, it will give you different information

EEG (electroencephalogram)

Capture electrical seizure activity Can be done with simultaneous video Can be done via "surgically placed internal grids" May do awake, asleep, or sleep-deprived Con: activity limitations, messy glue! *Looks at electrical activity of the brain tissue on the surface of the brain

Pathophysiology of increased ICP

Causes include space-occupying lesion (tumor, hematoma), brain swelling (trauma, infection, hypoxia), or imbalance of CSF dynamics *Causes of increases ICP are that you have something else that is then increasing the force against the skull. This may be something like a tumor, hematoma, swelling of brain tissue itself, or an imbalance in the CSF dynamics (remember, in a healthy person, you are constantly producing, circulating, and reabsorbing CSF)

Clinical Presentation of Meningitis

Classic Triad: -Severe headache -Fever -Nuchal rigidity (stiff neck or neck pain when turning) Malaise and photophobia common No single "hallmark sign" in children Non-specific illness progresses over 2-4 days LP shows cloudy fluid/high cell count/high protein/low glucose/organisms (bacterial). Normal glucose more suggestive of viral *Unfortunately not all patients will experience classic triad What is more universal is that the patient just doesn't feel well. They tend to feel more tired, they have a general malaise, often they are very sensitive to light Often starts as a non-specific illness (general "flu" feeling) that progresses over 2-4 days When a patient has an LP done, it will typically show cloudy CSF, there is a high cell count, often high protein and low glucose. If it is bacterial, you will be able to culture the specific organism If glucose level is normal, that is more suggestive of viral meningitis

Nursing Priorities with Head Bleeds

Crying for more than 10 minutes post-injury suggests serious injury! Airway - Breathing - Circulation - Disability ICP Management Principles Post-op craniotomy care Report suspected abuse/neglect Education for family re: long-term neurological sequalae *Regardless of the type of head injury, these are your nursing priorities Airway - Breathing - Circulation - Disability If the child hits their head, a good rule of thumb is that if the child continues to cry hysterically more than 10 minutes after injury, that suggests there is something seriously wrong. I expect the child to cry hysterically when they get injured, but most children can them be picked up, comfortable, and distracted, which will cause crying to stop With all of your head injuries, regardless of the specific type of injury, all of those ICP management principles will apply If the patient ends up going to surgery to either have a craniotomy or have a device placed, now they have also become a post-op patient With any sort of head injury, especially with a young child, you want to report any suspected abuse or neglect. In many institutions, it is standard operating procedure that if you have any traumatic injury in any child under the age of 4 that it automatically triggers at least an internal child protective services exam. Interview the child, interview the family, see if there is anything of concern Education for family re: long-term neurological sequalae, including the unpredictable nature of the recovery. After a brain injury, there is a lot of adjustments, not only for the patient but also for their family. A lot depends on the degree of injury and what section of the brain is injured. What is the role of the patient within the family? (are they employed, are they a caregiver, who is supporting them, are they supporting other people?) What happens in the days, weeks, months, years, after they recover from their injury and are discharged from the ICU?

Brudzinski's sign

With the patient supine, you flex their neck forward and they will reflexively pull their knees to their chest *pain with resistance and involuntary flex of hip/knee when neck is flexed to chest when lying supine

Corticosteroids

Dexamethasone (Decadron) Effective for treatment of focal edema from tumors, abscesses, and stroke Efficacy in head trauma has not been established Adverse effects -GI bleeding -Infection -Hyperglycemia *You may see corticosteroids used, especially if the head injury and increased ICP is due to an inflammatory process This is particularly helpful for patients who have brain tumors or they have a brain abscess and in certain kinds of stroke Corticosteroids do not work very well in patients who have had a traumatic head injury The problem with steroids is that there is a lot of side effects. The most concerning in these patients are: -GI bleeds -Infection -Hyperglycemia Because those are already complications of having increased ICP. Be extra alert when looking for signs of those complications. To prevent GI bleeds, administer a PPI or other GI prophylaxis along with the corticosteroid. Hyperglycemia - Maintain good glucose control, which may include an insulin infusion in critically ill patients (even those who are not diabetic)

Skull fractures

Difficult to fracture skull of an infant Linear -Most common fracture -Rare before 2 years of age Depressed -Malleable bone becomes dented Basilar -Very serious; can damage underlying structures -Risk for CSF leak/Meningitis *A bone in skull breaks. It is very difficult to fracture the skull of an infant, because their bones are mostly cartilage

Your 7-year-old patient was admitted with a basilar skull fracture after a fall from a tree. You notice some clear drainage from his nose and right ear and suspect a CSF leak. What are two simple tests you can do to confirm your suspicions?

First is that you could check glucose of clear fluid. Take glucometer strip, and take sample of clear fluid. Also need to check the patient's serum glucose (CSF glucose should be ~60% of serum glucose) Halo test - CSF will separate into layers (Halo sign). If it is bloody fluid, the blood will clot in the center, but then all the other components of the CSF will slowly ooze out. You will end up seeing darker ring on outer edge, and the clear serous fluid on outside (blood will always pool in the middle, because it is much heavier than CSF)

Health History - Neurological Assessment

HPI: "Tell me the story of what happened" Past History -Antental/perinatal/post-natal history in infants and toddlers -Timing and onset of developmental milestones (including play and school performance) -Childhood illness -Head/spine injuries Current History -Immunizations -Significant or chronic conditions -Medications -Substance use/smoke exposure/lead exposure/toxins *The health history has to be tailored appropriately based on the patient's age and developmental status when you are looking for a neurological alteration Under Past History -For a child under about the age of 2, the prenatal history is very important. -Did the mom get prenatal care? -Were there any complications during the pregnancy or delivery -Did the baby go home right away or did the baby have to go to the NICU -The timing and onset of developmental milestones -Need to know normal to recognize abnormal -As children get older, this includes asking questions about how they play, how they are doing in school, because those can be signs of an underlying neurological process -Ask about any short of childhood illness -Ask about any sort or head or spine injury Under Current History: -Substance use/abuse, with infants you are also worried about prenatal exposure to those substances, but even post birth: Are they exposed to smoke? Are they exposed to any short of toxin? Especially in children, lead exposure

Dura Mater

Hard double layer contains epidural space and venous sinus Subdural space (between dura and arachnoid) contains small bridging veins

Pupura

Hemorrhage into the skin with obvious discoloration The cause of pupura in meningitis is very similar to the cause in sepsis. It is ruptures of blood vessels and impaired perfusion Patients with meningitis, even if they survive, may end up losing fingers, toes, or entire limbs as a result of the pupura and impaired perfusion Strategies to improve damage from purpura include: -IV vasodilators -Nitroglycerine paste on effected area to again vasodilate and improve blood flow to those areas

Manipulating MAP

Hypotension is BAD -Volume resuscitation ---At high-risk for DI or SIADH -Vasopressor *We know that patients who have a head injury who have even one episode of hypotension, there mortality and morbidity rates go up exponentially, so it is critically important that you are maintaining adequate BP at all times These patients may need to get lots of IV fluids for volume resuscitation, and keep in mind these patients can often develop DI or SIADH or even vacillate between the two of them If your patient is in DI and putting out a liter of urine and hour, you will not only have to replace that liter of fluid as they are urinating, but also additional fluids to maintain their MAP. The problem is that them they flip into SIADH, and all of a sudden you have to fluid restrict them. It is back in fourth sometimes on an hourly or half-hourly basis If despite fluid resuscitation the patient still doesn't have an adequate MAP, this is when you will use your vasopressors. (just like in septic shock, if you fill the tank and you still do not have adequate blood pressures, you start bringing on your vasopressors) In head injury, Neosynephrine is often used, because it doesn't have an effect on the CO like many of the other vasopressors (such as dopamine and dobutamine)

ICP monitors

ICP monitors or drain can be placed in the -Epidural space -Intraparenchymal space -Subarachnoid space -Ventricular space -Subdural space Named based on location, and that also helps guide whether or not you expect to see fluid coming out of that drain and what it would look like If it is in the Ventricle, there will always be fluid produced, because you are going to be getting CFS Where as if you have an Epidural drain, it will only drain until bleed is gone, then you would not expect anymore output

Glasglow Coma Scale

Important measure of LOC. It includes three components: -The best Eye Opening -The best Verbal Response -The best Motor Response It is scored on a scale of 3-15. No eye opening, no verbal response, no motor response = score of 3 If the patient is fully conscious -4 for eye opening -5 for verbal response -6 for spontaneous motor response

Cerebral Angiography

Injecting contrast under fluoroscopy to look for the anatomy of specific blood vessels or areas of obstruction

Decerebrate

extension away from body, pronation of arms/legs

Decorticate

flexion into body,

Adults and older children - Clinical Presentation Increased ICP

get more of the classic symptoms -Headache, -Diplopia, -Blurry vision

Observation - Neurological Assessment

Interaction with environment/caregiver -Key: What is baseline? -Acute vs. gradual change Degree of alertness, irritability Response to painful stimulus Growth/development (Remember: you must know "normal" to detect "abnormal") Abnormal movements, including seizures -Asymmetrical movements -Cry - the "neuro cry" - unusual giggle/laughter etc. *For your physical exam, observation is really the most powerful tool that you have. Before the patient even sees you, observe how they are interacting with their environment or caregiver. You do have to understand what their baseline is, and often the caregiver will give you insight to that. If the caregiver reports there has been a change in the child's mental status or neurological function, ask, "Did this happen very quickly? or was it gradual/overtime?" (gives you clues to what underlying process is) Response to pain is very important. This is very true especially in children. Again, you need to go back to normal growth and development. If we think about a toddler, I am a stranger, I've taken them out of their normal environment, I'm taking away their body control, and I'm doing things that are unpleasant and that they don't want to do. If I am doing a painful procedure, such as starting an IV, I would expect a healthy toddler to fight me, cry, push me away, bite, spit, etc. If I am placing an IV in a toddler and they are very relaxed about it, that is very concerning and not a normal response of a toddler (response to pain is a KEY neurological clue) "Neuro cry" - think of this more with children, but may see with adults as well. It is this very monotone, harsh sounding cry. May also see an unusual giggle or inappropriate laughter (this can also be a sign of what happens during a seizure as well). The neuro cry has to do with the irritation to the meninges, so if you start hearing the neuro cry, this is very concerning

Brain Death

Irreversible cessation of all brain function, including brain stem (brain is completely dead, there is not functioning) NOT a "coma" or "vegetative state" (those patients have not achieved brain death) Determination process varies by state law and age (different process that has to occur the younger the patient is) All U.S. states use either irreversible cardiopulmonary arrest or brain death for determination of death - criteria may vary in other countries

The power of observation

Kid looks good -Alert -Interactive -Positioned appropriately for age; Tucked upper extremities, holding head up right -Responding appropriately to caregiver Kid doesn't look well (Dehydrated infant, hypovolemic shock) -Child is splayed out (poor muscle tone) -Head is thrust back -Eyes are rolled back -Color is not as good (grayish) -Child is not interacting with environment *Observation is critically important, especially when you are worried about neurological function

Nursing Priorities for increased ICP

Maintain ABCs (airway, breathing, circulation) Monitor labs, intake/output, and vitals closely Meticulous drain/wound care Protect injured area (e.g: helmet for bone flap). Positioning/Skin care/Early PT and OT Nutrition Sedation/Pain management Decreased stimulation (limiting noise, lights, "noxious" activities, visitors) *Maintain ABCs (airway, breathing, circulation) Monitor labs, intake/output, and vitals closely - because all of the interventions will be based on these findings Meticulous drain/wound care - because you have a pathway for microrganisms that puts them at risk for Meningitis Protect injured area (e.g: helmet for bone flap) - For example, for a patient that has has had a craniectomy (bone flap removed), you now have exposed brain tissue, so these patients will be fitted for a helmet to protect open area Positioning - These are patients who are very challenging to position (head up, midline, not too much bend at hips, etc). These are not patients you will be able to do a 180. degree turn on to each side, but they still have to be repositioned, so be very creative about how you reposition them and DOCUMENT if you are not able to reposition them in the way that is in alignment with the normal standard of care Skin care - protect heals, coccyx, back of head (occipital area). All the areas we know are at high risk for pressure injuries Get PT and OT on board early - Remember that even before the patient is able to participate, these are patients that may need splinting and aggressive passive ROM if they are not alert and moving themselves Nutrition - so important, especially in patients who are critically ill. Start nutrition early Maintain Sedation/Pain management using. appropriate scales Decreased stimulation (limiting noise, lights, "noxious" activities, visitors) - create a healing environment. Things like suctioning and repositioning are things we have to do, but these things will dramatically increase the patients ICP, so again strategize how you might cluster or break up your care. For example, the patient may need additional sedation before you suction them. Help families understand how best to interact with the patient (hearing is the last sense to go. It is important the people who love and care about them are there and present, talking to them, letting them know they are there). Help families understand what is too stimulating (maybe playing with there hair increases ICP, but stroking. their hand does not)

Epidural Hematoma

Much less common than subdural bleed Arterial bleed between skull and dura Uncommon in children under 4 years. More common in older children and adults Symptoms-free period can be longer than 48 hours "Talk and die" phenomenon *Occur not very often, but when they do occur, they are very scary. The patient can be symptom-free for 24-48 hours, meanwhile, they are having a ton of blood loss (because arterial blood). At some point, they reach a critical volume of blood loss, and they will go from fine to not fine within an instant "Talk and die" phenomenon. Where the patient comes in talking. Then all of a sudden, they are dead because of this critical blood loss. Epidural bleed will build up over time, and once it reaches critical point in ICP, the patient will herniate

Neurogenic Pulmonary Edema, GI Bleeding, DIC (Potential Complications of Increased ICP)

Neurologic injuries can cascade into multisystem damage

Kernig's and Brudzinski's signs

Not all patients present with Kernig's and Brudzinski's sign, but you need to put the pieces together. If the patient has a fever, photophobia, general malaise, and they have a positive Brudzinski's Sign, that is definitely in alignment with Meningitis

Secondary Brain Injury (Reperfusion Injury) (Potential Complications of Increased ICP)

Not just the initial insult that causes the damage. It can also be the oxidative injury that occurs once blood flow is restored This has been one of the big drivers behind the therapeutic hypothermia after cardiac arrest, because the hypoxic event causes damage to the brain, but what causes worse damage to the brain is actually once you have gotten spontaneous circulation back and now you are reperfusing that hypoxic brain

Nursing Implication of CT scan

Nursing Implications: -Lead protection -IV access -Distraction -Consider renal function *Anytime you are giving a patient contrast, that is a HUGE burden to their kidneys, so you need to consider renal function and whether the dose of contrast needs to be adjusted or if you need to do some renal protective interventions first

Meningococcal Meningitis

Often in adolescents/young adults due to close contacts (spread through droplet and touch) Notable purpuric rash in half of cases (purpuric bruises in the presence of other meningitis symptoms is very concerning) Illness often becomes fulminating in <24 hours and is often associated with a poor outcome

25%

the brain receives up to ____ of cardiac output *The metabolic needs of the brain are altered with a head injury The brain is a very demanding organ. It receives up to 25% of ones CO, because the brain tissue requires a constant supply of oxygen and glucose

Manipulating ICP (continued)

Osmotic diuretics (mannitol, 3% saline) Maintain normothermia (or mild hypothermia) Avoid seizures Mild hyperventilation (PaCO2 32-35) Promote cerebral drainage -Head of bed elevated at least 30 degrees -Head midline -Avoid sharp hip bends -Avoid ventilator pressures and gastric distention Create low-stimulation environment: -Environmental factors (light, noise, touch) -Sedation *Other medications you may see used are osmotic diuretics. The most common ones used are mannitol or hypertonic saline. The brain is a semipermeable membrane, so you will have osmosis (movement of water) in and out of the brain depending on the osmolarity of the body. If the osmolarity of the body is higher, water will move out of the brain and into the body to try and dilute that osmolarity (making osmolarity of body higher to try to draw water from the brain and hopefully lower ICP Maintaining noromothermia helps to decrease metabolic needs of brain and control the ICP. When someone is febrile, there ICP will go up exponentially. Again, our goal is to maintain normothermia or even mild hypothermia in order to control ICP Seizures will also increase ICP, so control seizures by prophylactically administering antiepileptics is often done Mild hyperventilation. Again, these patients are mechanically ventilated at this point, so you can intentionally hyperventilate them so that there PaCO2 is on the low end of normal or slightly below (range of 32-35)

Brain herniation

Part of the brain migrates into an area where it wasn't there before It is about where in the brain you have movement from the brain tissue

Bacterial Meningitis

Peak in fall and winter Survival has improved greatly with antibiotics and vaccination

Barbiturate Therapy

Pentobarbital or Thiopenal Indications --Uncontrolled ICP (ICP >20 or CPP <50) for 30 minutes Requires intubation with monitoring (including continuous EEG) Vasopressors may be needed Temperature instability *If despite all those interventions patients are still having increased ICP, you may see Barbiturate Therapy used with Pentobarbital being most common This requires intubation with monitoring, including a continuous EEG Basically, we are putting the patient into a Barbiturate Coma. Normally on an EEG, you get lots of squiggles and an occasional burst where there is lots of activity, then it settles down. What you are trying to do is give them enough Barbiturate that you essentially get a flat line for almost the entire screen. You want an occasional burst, but them you want it to go away (back to flat line). You are looking for "BURST SUPPRESSION." This tells you the patient is in a deep enough coma that you can basically medically control their ICP Barbiturate cause a lot of hemodynamic instability, so if your patient was not on vasopressors already, at this point, they will most likely need to be on vasopressors Barbiturates also causes a lot of temperature instability, so again, if it makes them cold, that will help you out (goal anyway), but you may see some extreme hyperthermia, so you will need to do various interventions such as ice packs or cooling mattresses to maintain a normal body temperature

Nursing Implications for MRI

Plan ahead, metal screening *Takes some planning ahead, for example, IV pumps cannot go into the room where the MRI scanner is, so this is where you will see nursing extending the IV infusion with the number of tubing sets that are needed for the particular room Careful screening of the patient and what you have as a clinician in your pocket, on your body, around your neck to ensure you are kept same and the patient is kept safe Be careful of portable O2 tanks Iodine allergy: There are some non-iodine based contrasts. It also depends on the severity of reaction. Might need to just medicate the patient with some benadryl and steroids first to midigate allergic response (risk vs. benefit) When the contrast goes in, most patients report (warn patient): -A warm flushing feeling -Feel like they are urinating or need to urinate

Increased Intracranial Pressure (ICP)

Pressure exerted by blood (10%), CSF (10%), brain tissue (80%)... and any other space occupying fluid or mass "Normal" ICP is 0-15 mmHg "Increased ICP" is sustained (greater than 5 minutes) pressure above 20 mmHg How high is too high? How high can ICP actually go? *ICP is the pressure that is exerted within the fixed skull cavity by blood, CSF, brain tissue, and anything else that happens to be in the cerebrum at the time

Clinical Pearl - Increased ICP

Pupils will dilate on SAME SIDE (ipsilateral ) to injury Motor effect (e.g. paralysis) will be on OPPOSITE SIDE (contralateral) to injury *Remember how cranial nerves and motor function of brain operate Pupil on the same side of injury will become fixed and dilated, because that is the cranial nerve that intervates that eye The motor effects/deficits and sensory effects/deficits from that injury will be on the opposite side

Manipulating ICP

Remove offending process -Tumor resection -Evacuation of hematoma -Drain/bolt placement -Craniectomy/lobectomy *To manipulate the ICP, the best action is to remove whatever is causing the increased ICP to begin with If the increased ICP is being caused by a tumor, we need to surgically resect that tumor If the increased ICP is due to a hematoma, then we need to drain that hematoma You may see different invasive devices used. Different drains can be put in place to either drain CSF or blood. You may also see bolts placed in different layers of the brain, which cannot drain fluid, but allow you to measure the ICP from within the brain tissue In severe cases where you cannot manage the ICP just though medication management, patients may need to have a Craniectomy done where the skull will actually be open up and a section of the skull is removed. Basically, we have created a fontanel in and older patient. Give then a "pop-off valve," so the brain tissue can swell and expand without being compressed. If a section of the skull has been removed, there are two places it can be stored. It can be cryogenically frozen in the lab freezer or within the patients abdomen (preferred). When it is kept within the patient's body, it is still being exposed to the patient's antibodies and blood flow, so the bone flap tends to stay healthier (Maintain bone health). Can also get lost if in lab fridge. If the craniectomy still doesn't work, a lobectomy may be considered where brain tissue is actually removed in order to decrease the size of the brain and reduce the pressure (lobectomy will have implication on lost brain function)

occiptal lobe

visual processing

Nursing Priorities for Meningitis

Safety--Droplet precaution for full 24 hours of antibiotic therapy ABCD (Airway, Breathing, Circulation, Disability) PROMPT antibiotics (as soon as cultures collected) are essential to survival ICP management/sepsis mangement Maintain tissue perfusion and skin integrity People exposed to untreated patient may need antibiotic prophylaxis Promote broad vaccination at all ages *First thing is make sure the scene is safe. Meningitis is infectious to you as well, so the first step is to place patients on droplet precautions for a full 24 hours after antibiotic therapy before the patient is no longer contagious Then, your priorities center around airway, breathing, circulation, and disability PROMPT antibiotics (as soon as cultures collected) are essential to survival. This is very similar to sepsis where time is of the essence. Get in, get cultures, get antibiotics started ASAP Then, it becomes management of ICP and septic shock Maintain tissue perfusion and skin integrity, because you have a patient that have both uncontrolled ICP and essentially sepsis. The skin is an organ, and skin failure can result People exposed to untreated patient may need antibiotic prophylaxis (rocephin). Generally prophylaxis is limited to those who have had close prolonged contact with untreated patient Promote broad vaccination at all ages. Not just childhood vaccine, but also what does the patient need as an adolescent

Lumbar Puncture

Spinal needle is inserted usually between the 3rd and 4th lumbar vertebrae into the Subarachnoid space, which contains CSF AKA "spinal tap" Pressure measurement, CSF sample, therapeutic drainage, chemo administration Con: Headache, painful, sedation risks, injury *May see this done for diagnostic or therapeutic reasons For patients who produce too much CSF, you can do therapeutic drainage You can give chemotherapy directly into the CSF (this is particularly helpful with CNS tumors) Like an epidural, it is about inserting a needle into the subarachnoid space then placing a catheter to withdraw a sample

Auto-regulation

Supply must equal demand

Meninges

The membranes covering the brain and spinal cord

Brain Tissue Death (Potential Complications of Increased ICP)

The worst is brain tissue death. Although there is some plasticity in the neurons (especially in younger children, they can rewire what part of the brain controls what), eventually if you have significant brain tissue death, that is not going to be replaced, so you may have loss of some brain function

pia mater

Thin inner later adheres to brain and spinal cord

Health History - Family History

Think outside of the head! Many other body problems may present with neurological symptoms -Neuro: static/progressive, acquired/congenital -Endo: diabetes, thyroid, hormone imbalances -CV: congenital heart disease, arrhythmias, aneurysms -Congenital: neural tube defects, metabolic disorder -Genetic disorders: chromosomal, epilepsy, migraines -Liver/Renal *Liver failure - when someone has encephalopathy, they will present with neurological symptoms or mental status changes. Even though it is a liver problem, it will end up causing a neurological alteration

Head injuries

Unintentional head injuries (including MVA and falls) are a leading cause of traumatic brain injury for all ages: --Those aged 75 and older have the highest rates of traumatic brain injury-related hospitalization and death due to falls --Trifecta of Pediatric Head injuries: MVA, falls, and recreational injuries -"Shaken baby syndrome" -Violence (self or other) -Submersion injury/suffocation -Kids are much more prone to head injuries, because they are "top heavy." Develop from head-to-toes. Proportionately the head is the largest and heaviest part of a child's body, so it will be projected forward first (will have more head injuries than say an adult if in same care accident) Subdural hematomas and brain hemorrhages (CVA, ateriovenous malformation, ruptured aneurysm) All TRAUMATIC head injury patients are assumed to have a cervical spine injury until proven otherwise

Labs that are important in patients with neurological alterations

Urine -Sodium -Osmolarity -Toxicology screen Serum (Blood) -Sodium -Osmolarity -Glucose -Drug levels -Toxicology screen -Arterial blood gas CSF -Culture -Gram Stain -Glucose -Protein -Cell Count -Other cytology/serology *Some of the most important labs we evaluate are Sodium and Osmolarity CSF, much like serum, we can look at the types of cells that are in it and we can also send a culture and gram stain (we would not expect to see any microorganisms)

Transcranial Doppler

Using ultrasound Often used in patients who may have carotid artery obstruction who are at risk for stroke

Concussion

Violent jarring or shaking that results in a disturbance of brain function Traumatically induced alteration of consciousness Loss of consciousness is not required May have amnesia of event Unclear pathology: shearing forces? May see coup-contrecoup injury *Important to note that someone doesn't have to lose consciousness in order to actually have a concussion. They just need to have something change in their level of consciousness Often patients who get a concussion will have amnesia of the event We don't have a clear understanding of what actually causes a concussion. There is some thought that it is shearing forces on the neurons or neurons are getting stretched You may also see a coup-contrecoup injury. Coup injury occurs under the site of impact with an object, and a contrecoup injury occurs on the side opposite the area that was hit. First bump of wall hits skull. Remember, the brain is suspended in CSF and free-floating, so the skull will stop but brain will still move. The brain moves forward and then slams on inside of skull. Now you have a second injury there, but the force is so high that once the brain hits the front, it will then bounce backward and hot the back of the skull, so there are two areas of potential injury on the brain. The front part of brain where it hit the front of skull, then the ricochet movement where it hit on the back of the skull For a concussion, there is no visible injury to brain tissue on a CT scan. Concussions are diagnosed based on clinical presentation (altered level of consciousness, something has changed in patient's presentation)

Contusion/Laceration

Visible bruising/tearing of brain tissue Symptoms similar to concussion *With most minor injuries, it is not indicated to do a CT scan, because it will not change management at all

Evoked Potential Studies

When it EEG done invasively and it is stimulating different sections of the brain electrically to look at the responsse