1. Supplemental Neuro PP

2. 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

3. 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

4. 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.

5. 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

6. 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

7. 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;

8. 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

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

10. 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

11. 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