Cerebral Dysfunction
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| Assessment of Cerebral Function | Family History: genetic disorders with neurologic manifestations
Health History: Clues to cause of dysfunction
Physical Evaluation
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| Cranium Total Volume | Brain 80%, CSF 10%, and blood 10%
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| Increased Cranial Pressure | An increase in ICP may be caused by tumors or other space-occupying lesions, accumulation of fluid within ventricular system, bleeding, or edema of cerebral tissues.
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| Consciousness | Alertness: an arousal - waking state including the ability to respond to stimuli.
Cognitive Power which includes the ability to process stimuli and produce verbal and motor responses.
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| Infant Clinical Manifestions of ICP | Tense/ bulging fontanel, separated cranial sutures, irritability, high-pitched cry, distended scalp veins, change in feeding habits, cracked pot sound on percussion, crying when disturbed
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| Children Clinical Manifestations of ICP | Headache, Nausea, Vomiting, blurred vision, seizures
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| Personality and Behavioral signs | Irritability, restlessness, indifference, drowsy, increased sleeping, decline in school performance, memory loss, lethargy. inability to follow commands
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| Glascow Scale | Pupils, eye opening, verbal response, and motor response
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| Vital Signs | Body temp is often elevated . Pulse is variable and may be rapid slow and bounding. BP may be normal elevated or at shock level. Hyperventilation is usually a result of metabolic acidosis or abnormal stimulation of the respitory center
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| Motor Function | Asymmetric movement of the limbs or absence of movement suggest paralysis. Tremors, twitching and spasms are common
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| Flexion posturing | Flexion posturing- is seen with severe dysfunction of cerebral cortex or with lesions to the corticospinal tracts above the brainstem. Arms tightly to body , flexed elbows, wrists, and fingers, legs extended and rotated in, plantar flexed feet
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| Extension posturing | Is a sign of dysfunction at the level of the midbrain or lestions to the brainstem. Rigid extension, pronation of arms and legs, flexed wrists and fingers, clenched jaw, extended neck, and arched back.
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| Reflexes | Absence of corneal reflexes and presence of tonic neck reflex is associated with severe brain damage.
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| Signs of pain in comatose pt | change in behavior, increased heart rate, respiratory rate, and blood pressure, and decreased oxygen saturation.
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| Intracranial pressure monitoring | GCS evaluation of 8, GCS less than 8 with respiratory assistance, deterioration of condition, clinical appearance and response.
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| Cerebral Trauma | The three major causes of brain damage are falls, motor vehicle injuries and bicycle injuries.
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| Brain Injury | Is related to the force of impact. Intracranial contents are damaged because the force is too great to be absorbed by the skull and support the head.
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| Head Injuries | Primary head injuries occur at the time of trauma and include skull fracture, contusions, intracranial hematoma, and diffuse injury. Complications include hypoxic brain damage, increased ICP, infection and cerebral edema.
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| Acceleration/Deceleration | Demonstrate generalized cerebral swelling produced by increased blood volume or a redistribution of cerebral blood rather than increased water content.
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| Concussion | transient and reversible neuronal dysfunction with instantaneous loss of awareness and responsiveness that results from trauma to the head .
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| Epidural Hemorrhage | The blood accumulates between the dura and the skull to form a hematoma forcing the underlying brain contents downward and inward as the brain expands.
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| Subdural Hemorrhage | Bleeding between the dura and the cerebrum, usually as a result of rupture of cortical veins that bridge the subdural space. Tends to develop more slowly spread thinly.
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| Manifestations of Minor Head Injury | Transient period of confusion, somnolence, listlessness, pallor, vomiting, irritability.
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| Severe head injury | Signs of ICP, Increased head size, bulging or full fontanel, retinal hemorrhage, hemiparesis, quadriplegia, elevated temp, unsteady gait, papilledema.
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| Drowning | Drowning: death from asphyxia while submerged regardless of whether fluid has entered the lungs.
Near-drowning- survival at least 24 hours after submersion in medium fluid.
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| Pulmonary changes during drowning | Directly related to the length of submersion, victims physiologic response, and development/ degree of immersion hypothermia.
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| Hypoxia | Neurons sustain irreversible damage after 4-6 minutes. Heart and lungs can survive up to 30 min.
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| Brain Tumors | Most common solid tumor in children and second most common childhood cancer.
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| Signs and Symptoms | Directly related to the anatomic locations, size, and child's age. Headache, vomiting
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| Treatment of brain tumor | May involve the use of surgery, radiotherapy, chemotherapy. Treatment of choice is complete removal of tumor. Radiotherapy shrinks the tumor before attempting surgical removal.
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| Post op care | If tumor was removed the child is not placed on operative side , since the brain may shift to that cavity, causing trauma to the vessels, lining and brain. Neurologic checks are essential, drainage of site is estimated and recorded.
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| Neuroblastoma | Onset of disease is typically before 10 years of age. It is a "silent" tumor. Majority of tumors develop in the adrenal gland or the retroperitoneal sympathetic chain
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| Meningitis | Caused by a variety of organisms : bacterial, viral or aseptic, tuberculous
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| Bacterial Meningitis | Inflammation of the meninges and CSF. Can be caused by a variety of bacterial agents including H. influenzae type b, S. pheumonaie, and Neisseria meningtitis.
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| Route of infection of bacterial meningitis | Vascular dissemination from a focus of infection elsewhere. Also gain entry by direct implantation after penetrating wounds, skull fractures, lumbar punctures, or foreign bodies.
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| Infection process | inflammation, exudation, white blood accumulation and varying degrees of tissue damage. The entire surface of the brain is covered in a layer of purulent exudate that varies with type of organism. May obstruct the flow of CSF
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| Signs of Bacterial Meningitis | Abrupt onset, fever, chills, headache, vomiting, seizures, agitation, irritability, nuchal rigidity, positive kernig and brudzinski signs, hyperactive reflex responses, poor feeding
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| Diagnostic Evaluation | Lumbar puncture is the definitive test, elevated WBC, glucose decreases, protein concentration increased.
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| Therapeutic Management | Isolation precaution, antimicrobial therapy, maintenance of hydration and ventilation, reduction of increased ICP, control of seizures and temp, treatment of complications.
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| Aseptic Meningitis | Caused by many different viruses. Headache, fever, malaise, and GI symptoms
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| Encephalitis | Inflammatory process of the CNS that is caused by a variety of organisms.
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