Neuro Disorders Study Outline Pediatric Brain Tumors

Brain tumors can arise anywhere within the brain structures Primary tumors originate in CNS Secondary tumors result from metastasis Tumors can lead to cerebral edema, brain tissue inflammation, increased ICP, focal neurologic deficits, obstruction of cerebrospinal fluid flow, pituitary dysfunction Diagnosis Signs and symptoms are related to anatomic location, size, childs age Headache (am) and vomiting MRI, CT, EEG, angiography Lumbar puncture is risky with increase ICP Definitive diagnosis tissue pathology report Treatment Treatment depends on type of tumor Surgery o Total removal without neurologic injury Radiotherapy o May be used to shrink tumor before surgery Chemotherapy o Adjunct therapy for residual, recurrent, or inoperable tumor o Water soluble agents cross BBB Radiation therapy Chemotherapy Analgesics Dexamethasone Phenytoin Ranitidine hydrochloride Stereotactic radiosurgery (Gamma Knife) Nursing Care Prepare child and family for diagnostic and operative procedures Postoperative care o Close monitoring of vital signs o Cooling blanket for post-op hyperthermia o Neuro checks o Sluggish reaction, dilation, or unequal pupils may be first indication of increasing ICP o Correct positioning to prevent operative site pressure, reduce ICP, and avoid aspiration o Surgeon will prescribe position restrictions, including degree of neck flexion o Two nurses reposition patients in the first 24-48 hours to prevent any misalignment o Trendelenburg position is contraindicated; even for shock

Cerebral Tumors Headache Vomiting Vision changes Hemiparesis, hemiplegia Hyperesthesia, paresthesia Seizures Aphasia Personality change

Brainstem Tumors Hearing loss (acoustic neurons) Facial pain, weakness Dysphagia, decreased gag reflex Nystagmus Hoarseness Ataxia, dysarthria

Meningitis
Inflammation of the meninges that surround the brain and spinal cord

Bacterial meningitis
Potentially life-threatening Medical emergency Mortality rate: 25% Mortality rate near 100% if untreated Organisms enter CNS from respiratory tract or bloodstream o Streptococcus pneumoniae o Neisseria meningitidis Vaccinations recommended for all children , adolescents, and up to age 55 years o Meningitis polysaccharide vaccine (MPSV4) o Haemophilus influenza (Hib) o pneumococcal vaccines Often secondary to viral respiratory disease o Otitis media o Pneumonia Infection produces inflammatory response in the pia mater, the arachnoid, the CSF, and the ventricles o Increased ICP o Increased CSF production o Purulent secretions spread to other areas of brain through CSF

Clinical Manifestations of Bacterial Meningitis Headache, nausea, vomiting, and fever Photophobia Nuchal rigidity Kernigs and Brudzinskis signs May be positive in only a small percentage of patients having meningitis Meningococcal meningitis Skin rash is common Petechiae Coma has poor prognosis. o Occurs in 5% to 10% of bacterial cases Seizures occur in one third of cases o Irritation of cerebral cortex o SIADH

Bacterial Meningitis Interventions Broad-spectrum antibiotic o Narrow coverage when organism identified o 14 days IV antibiotics o Cross blood-brain barrier Ampicillin, penicillin Vancomycin Cefuroxime (Ceftin), cefotaxime (Claforan), ceftriaxone (Rocephin), ceftizoxime (Cefizox), and ceftazidime (Ceptaz) Increased ICP o Hyperosmolar agents Seizures o Anticonvulsants Steroids o Controversial o Streptococcus pneumonia meningitis

Viral Meningitis
Most common causes are enterovirus, HIV, and HSV. Usually presents as headache, fever, photophobia, and stiff neck Diagnostic testing of CSF o Lymphocytosis o No organisms from Gram-stained or acid-fast smears o PCR to detect viral-specific DNA/RNA Symptomatic management

Guillain-Barr Syndrome
Demyelination of the peripheral nerves o Destruction of the myelin sheath o Progressive motor weakness o Sensory abnormalities Ascending paralysis o Symptoms begin in the legs, and spread to arms and upper body Result of a variety of related immune-mediated pathologic processes Muscle weakness and pain have abrupt onset Cerebral function, pupil response not affected Cranial nerve involvement o VII Facial nerve o X - Autonomic dysfunction: unstable BP, HR o IX and X cough, gag, swallow

Interventions for GBS Immunoglobulin Plasmapheresis Monitoring respiratory status Managing cardiac dysfunction Improving mobility and preventing complications of immobility Managing pain Promoting communication Providing emotional support

Skull Fractures Linear Low velocity injury Break in continuity without change in relationship of parts

Depressed Powerful blow Indentation of skull fragment

Comminuted Direct, high momentum impact Multiple linear fractures, with fragmentation Compound Severe head injury Depressed skull fracture with intracranial communication

Signs of a Skull Fracture

Periorbital ecchymosis Ecchymotic areas surrounding both eyes, suggestive of a basilar skull fracture

Battles Sign Indicates a posterior basal or base of skull fracture and potential brain injury

Halo Sign The halo sign is present when nasal secretions on bed linens or dressings form a halo. This occurs when CSF, mixed with blood, spreads onto an absorbent surface. The darker blood chromatographically forms a ring around a lightly-stained center, forming a halo. Mixture of blood with tears or saliva can give falsepositives Check for glucose in leaking fluids

Seizure Disorders
Abnormal, sudden, excessive, uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior Most common neurologic dysfunction in children Etiology Epilepsy Acute symptomatic seizures More than two unprovoked seizures o After acute insult Idiopathic epilepsy: cause unknown Head trauma Seizures are indispensable characteristic of Meningitis epilepsy Remote symptomatic seizures A single seizure not generally classified as o No immediate cause epileptic o Prior brain injury Single seizure not generally treated with Cryptogenic seizures long-term medications o No clear cause Idiopathic seizures

Partial seizures: Begin in one area of the brain and are not spread throughout both hemispheres. Usually associated with LOC Simple partial seizures o Consciousness not impaired Complex partial seizures o Consciousness impaired

Generalized seizures: Begin in one area of the brain and spread throughout both hemispheres. Usually associated with LOC. Generalised Tonic Clonic Seizures Previously referred to as grand mal and are sometimes called a fit or convulsion. They are the most universally recognised seizures. They often begin with a sudden cry. If standing, the person will fall to the ground and lose consciousness. The body becomes quite stiff (tonic) shortly followed by jerking of the muscles (clonic). Breathing is shallow or temporarily suspended causing the lips and complexion to look grey/bluish. Saliva (sometimes also blood if the tongue has been bitten) may come out of the mouth, and there may be loss of bladder control. The seizure usually lasts approximately two minutes and is followed by a period of confusion, agitation and extreme tiredness. Headaches and soreness are also common afterwards. Absence Seizures These seizures, previously referred to as petit mal, almost always begin in childhood and are commonly mistaken for daydreaming and inattentiveness. They are characterised by staring, loss of facial expression, unresponsiveness, cessation of activity and eye blinking or upward eye movements. They start and end abruptly, and last approximately two to 20 seconds. Most people recover their mental function immediately and return to their previous activity, with no memory of the event. Children who have absence seizures often have normal cognitive function and intelligence, although if the condition is not treated it can create gaps in learning due to the seizures occurring many times a day. Myoclonic Seizures These are brief but significant muscle jerks which usually involve the upper body but can involve the lower or whole body. The person may drop or spill what they are holding or fall off a chair. There is no impairment of consciousness, but if several seizures occur over a short period of time the person may feel slightly confused or drowsy. These seizures frequently occur shortly after awakening. Tonic Seizures* These are a brief stiffening of the muscles of the whole body which cause it to go rigid. If a person is standing, they will fall rapidly to the ground. Recovery is swift, but injuries can be sustained. These seizures can also occur in sleep. Atonic Seizures* Atonic seizures are a sudden, brief loss of muscle tone of the whole body. Once again, the person will abruptly collapse to the ground, usually head first, so facial and head injuries are common. There is no noticeable loss of consciousness and the person usually recovers swiftly unless injured. *Note: Tonic and Atonic seizures are also known as drop attacks and are more likely to occur in people with severe epilepsy and multiple seizure types.

Status Epilepticus Medical emergency Prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes Establish an airway ABGs IV lorazepam, diazepam; rectal diazepam Loading dose IV phenytoin Seizure Disorder Interventions Oxygen and suctioning equipment should be readily available. Saline lock may be necessary Siderails should be up at all times Padded siderail use is controversial Place bed in lowest position Never insert padded tongue blades into the patients mouth during a seizure Pharmacology o Monotherapy is preferred o Gradual dose increase until seizure control or signs of toxicity o Lorazepam o Diazepam o Diastat o IV phenytoin or fosphenytoin Anticonvulsants may be discontinued o When seizure free for 2 years o Normal EEG o Avoid during puberty or when subject to frequent infections o Recurrence possible within first year CPR training for family members Rectal diazepam available for intractable seizures Activity restriction on individual basis Safety: must wear a helmet, no swimming alone, teachers and other caregivers must be made aware of condition Antiepileptic drugs (AEDs) may not be stopped, even if seizures stop