Intracranial Regulation 1

• Early

• Decline

• Late

• Altered LOC

• Behavioral changes

• Respiratory changes

• Disorientated

• Continuous stimulation to arouse

• Reflexive positioning to painful stimulus

No response to stilmulus (coma)

• Full Consciousness

• Lethargy

• Obtundation

• Stupor

• Coma

The patient is alert, attentive, and follows commands. If asleep, she responds promptly to external stimulation and, once awake, remains attentive.

The patient is drowsy but awakens—although not fully—to stimulation. She will answer questions and follow commands, but will do so slowly and inattentively.

The patient is difficult to arouse and needs constant stimulation in order to follow a simple command. She may respond verbally with one or two words, but will drift back to sleep between stimulation.

The patient arouses to vigorous and continuous stimulation; typically, a painful stimulus is required. She may moan briefly but does not follow commands. Her only response may be an attempt to withdraw from or remove the painful stimulus.

The patient does not respond to continuous or painful stimulation. She does not move—except, possibly, reflexively—and does not make any verbal sounds.

used to give a standardized numeric score of the neurologic patient assessment. This is a widely used measurement tool that consists of three components: eye opening, verbal response, and motor response

GCS score = 13-15

GCS score = 9-12

GCS score = 3-8

Less than 3

True or False: A child with a GCS score of 9-12 should be hospitalized

15

• Neuroimaging: CT/MRI

• Skull X-Rays

• EEG

• Brain biopsy: 

• Lumbar Puncture: CSF assessment

Lorazepam (Ativan)

• May require mechanical ventilation

• IV Fluids: possible fluid restrictions

• Control seizures: seizure precautions: Seizure drugs

• Medications to reduce ICP: Osmotic Diuretics Steroids

• ICP Monitors: Hyperventilate to reduce paCO2:

  • Bolt placement

• Surgical Procedures to reduce IICP:

  • Burr holes

  • Craniotomy

  • Internal/external shunts

• Monitoring ICP

• Vital Signs

• LOC and pupillary response to light

• Full respiratory assessment (w/ ABGs)

• Monitoring fluid intake and output

Rim of the sclera above the irises

•irritability/lethargy

•High Pitched cry

•Bulging, tense fontanel

•Wide cranial sutures

•↑ Head circumference

•Dilated scalp veins

•Poor feeding or vomiting

•Headache

•Vomiting (projectile)

•Dizziness

•↓ pulse and RR

•Blurred vision, Diplopia

•Sluggish, unequal  pupils

•↓ LOC, irritability

•Slurred speech

• Severely ↓ LOC

• ↓ motor & sensory response (PGCS)

• ↑ B/P, widened pulse pressure

• Bradycardia

• Irregular Respirations

• Cheyne-Stokes respirations

• Decerebrate & decorticate posturing

• Fixed & dilated pupils

Brain herniation

(refers to a set of signs that are indicative of increased intracranial pressure (ICP), or increased pressure in the brain.

consists of bradycardia,, irregular respirations, and a widened pulse pressure)

True or False: Cushing’s triad is indicative of a medical emergency and medical attention is required.

• Increased BP with widened pulse pressure

• Bradycardia

• Irregular respirations (also known as Cheyne–Stokes respirations)

  • Cheyne-Stokes respirations consist of periods of slow, deep breaths followed by periods of apnea, when breathing comes to a complete stop.

• Hypertension, or increased blood pressure

Sunset eyes is a(n) [Fill in the blank] of increased ICP in infants and toddlers with hydrocephalus

A brain condition that happens when Cerebrospinal fluid can’t drain from the brain.  It pools, causing a buildup of fluid in the skull. 

Ventriculo-Peritoneal Shunt (VP Shunt)

•  Lie flat for 24 hours (on unaffected side)

•  Vital signs and neurological status

•  Pain management

•  IV fluids

•  Antibiotics

•  The shunt will be checked to make sure it is working properly

•  Measure head circumference

•  Blood clot or bleeding in the brain

•  Brain swelling (monitor of s/s of increased ICP)

•  The shunt may stop working and fluid will begin to build up in the brain again

•  Infection

•  Damage to brain tissue

•  Seizures

• Headache

• vomiting

• drowsiness

• fever

need immediate evaluation!

Malformation of the spinal cord and spinal canal

Defect in vertebrae through which the spinal cord contents can protrude

• Occulta

• Meningocele

• Myelomeningocele

• Mildest form

• Small separation of the spinal bones

• Usually lower spine

• Abnormal tuft of hair

• Collection of fat

• Small dimple or a birthmark

• Spinal nerves aren’t involved

• No neurologic problems

Cause unknown

• Folic acid deficiency plays a part

• Genetic component

• Viral trigger

• Neural tube defect in a previous child

• Lack of folic acid

• Medications: valproic acid, carbamazepine

• Maternal diabetes

• 95% no known family history

•  Blood tests

  • Maternal serum alpha-fetoprotein test (MSAFP)

  • Human chorionic gonadotropin (HCG),

  • Estriol

•  Ultrasound

•  Amniocentesis

• X-rays, CT scans or MRI

  • performed after delivery to determine the  degree of the impairment

 Folic acid (vitamin B-9) 400 micrograms:

• start at least 1 month prior to conception and during the first trimester of pregnancy

• fortified breakfast cereals

• dark green vegetables

• egg yolks

• some fruits

Type of Neural Tube Defect

• Occurs when the neural tube fails to close (osseous spine)

Rarest form of spina bifida

• Protective covering around the spinal cord (meninges) pushes out through the opening in the vertebrae

•  Spinal cord develops normally

•  Sac can be repaired with very little damage to nearby nerves

 Most severe form

•  Spinal canal remains open along several vertebrae in the lower or middle back

•  Spinal cord and membranes protrude at birth, forming a sac on the baby’s back

•  Tissues and nerves are directly exposed

•  Neurologic impairment - partial or complete paralysis, is common

Involves surgery to put the meninges back in place and close the opening over the meningocele. This surgery usually occurs soon after birth.

Surgery within hours to several days after birth

• ↓ risk of infection

• Helps protect the spinal cord from additional trauma

• T_x hydrocephalus w/ ventriculo-peritoneal shunt

  Irreparable nerve damage has already occurred!