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Course: Pediatric Nursing

Topic: Nursing Care of Child with Neurological Disorder Part II

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Module Goals

Learners will be able to:

Identify factors associated with head trauma in children
Identify common signs and symptoms of head trauma in children
Identify risk factors associated with head trauma in children
Explain the role of the nurse in caring for children with neurologic conditions

Contact info: info@nursesinternational.org

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Head Trauma

Head trauma is common among children and results in a significant number of visits to emergency clinics
Children are more predisposed than adults to head injury because:

Head to body ratio is greater
Brains are less myelinated and
Cranial bones are thinner

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Risk Factors for Head Trauma

High energy mechanism

Fall from > 1 meter
Motor vehicle accident (MVA)
Assault
Projectile (e.g. golf, cricket ball)
Lack of history

Increased risk of bleeding

Thrombocytopenia or other haematological disorders
Medication (e.g. quinine, penicillin, digoxin, anti-epileptics, salicylates, heparin, warfarin)

Government of Western Australia: Child and Adolescent Health Services, July 2022

Contact info: info@nursesinternational.org

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Types of Head Trauma

Concussion

An injury to the head that may cause the brain not work normally for a short time
Can result in a loss of awareness or alertness for a few minutes up to a few hours

Contusion

A bruise on the brain that causes bleeding and swelling of the brain
Can happen from violent shaking of a child, or a whiplash-type injury from a motor vehicle accident

Stanford Children’s Health, 2022

Contact info: info@nursesinternational.org

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Types (continued)

Skull fracture (4 major types)

Linear:

A break in the bone that does not move
No treatment is needed

Depressed:

The skull is sunken where the bone is broken-may need surgery

Diastatic:

Occurs along the suture lines in the skull- suture lines widen
More often seen in newborns and infants

Stanford Children’s Health, 2022

Contact info: info@nursesinternational.org

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Types (continued)

Basilar skull fracture:

A break in the bone at the base of the skull can be serious
Often has bruises around eyes and behind their ear
May have clear fluid draining from nose or ears
Requires close clinical observation

Stanford Children’s Health, 2022

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

What education should be provided to parents regarding prevention of head trauma and if a child has a head injury?

Contact info: info@nursesinternational.org

The child should wear a helmet in contact sports and when bike riding, skiing, skateboarding. It should fit properly and be:

Well maintained
Age appropriate
Worn consistently and correctly
Appropriately certified for use

While there is no concussion-proof helmet, a helmet can help protect the child or teen from a serious brain or head injury. Even with a helmet, it is important for the child or teen to avoid hits to the head.

What Should I Do When a Child Has a Head Injury?

Call health care provider right away if the child had a head injury and:

is an infant
lost consciousness, even for a moment
has any of these symptoms:

won't stop crying
complains of head and neck pain (younger children who aren't talking yet may be more fussy)
vomits more than one time
won't awaken easily
becomes hard to comfort
isn't walking or talking normally

If the child is not an infant, has not lost consciousness, and is alert and behaving normally after the fall or blow:

Put an ice pack or instant cold pack on the injured area for 20 minutes every 3–4 hours. If ice is used, always wrap it in a washcloth or sock. Ice placed right on bare skin can injure it.
Watch the child carefully for the next 24 hours. If the injury happens close to bedtime or naptime and the child falls asleep soon afterward, check in a few times while they sleep.

If the child's skin color and breathing are normal, and no problem is sensed, let the child sleep unless the doctor tells otherwise. There's no need to keep a child awake after a head injury.

Trust the instincts. If child doesn't look or seem right, partly awaken the child by sitting them up. They should fuss a bit and attempt to resettle. If the child still seems very drowsy, try to awaken them fully. If can't be waken the child, call the health care provider or emergency service as per the country hotline.

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Head Trauma

History: Ascertain the following:

Mechanism of injury, time of injury
Loss of consciousness
Irritability
Visual disturbance
Disorientation
Abnormal gait
Lethargy, pallor or agitation may indicate severe injury
Vomiting, pain in other areas of the body
Ask about previous head injury and self treatment

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Physical Finding

Classification of Intracranial Injuries:

Mild:

Asymptomatic
Mild headache
No evidence of skull fracture, facial injury or other trauma
Three or fewer episodes of vomiting
Glasgow coma score 15
Loss of consciousness for < 5 minutes

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Head Trauma

Moderate Intracranial Injuries:

Progressive lethargy
Progressive headache
Signs of basal skull fracture; possible penetrating injury or depressed skull fracture; serious facial injury, multiple trauma
Vomiting protracted (more than three episodes) or associated with other symptoms
Glasgow coma score 11-14
Loss of consciousness for ≥ 5 minutes
Post-traumatic amnesia or seizures

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Head Trauma

Severe Intracranial Injuries:

Focal neurologic signs present
Penetrating skull injury
Palpable depressed skull fracture or compound skull fracture; serious facial injury or multiple trauma
Glasgow coma score ≤ 10
Unconscious

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Head Trauma (Physical Findings)

Vital Signs:

Temperature usually normal
Tachypnea: rapid heart rate may signify blood loss, in which case evidence of other injuries should be sought
Bradycardia with hypertension (Cushing response): usually a late response in children with increased intracranial pressure and therefore not very reliable
Hypertension: late sign of increased intracranial pressure
Hypotension signifies shock: look for other injuries, since shock is not a usual sign of brain injury, unless there is significant intracranial bleeding

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Head Trauma

Neurologic Examination

Observe gait
Examine nasopharynx and ears for evidence of fresh blood
Pediatric Glasgow Coma Score
Bulging fontanel, widely separated scalp sutures
Papilledema (increased intracranial pressure)
Pupillary light reflexes (PERRLA [pupils equal, round, reactive to light; accommodation normal])
Cranial nerve examination
Movement of extremities, deep tendon reflexes, sensory and motor functioning and coordination
Muscle flaccidity, spasticity

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Head Trauma

Indicators for intracranial pressure:

Decrease in Glasgow coma score of 2 points or more
Abnormality or changes in pupillary size and reaction to light
Respiratory abnormalities
Development of paresis in absence of shock
Hypoxia
Seizures
Elevation of blood pressure, Wide pulse pressure
Decrease in heart rate
Decrease in respiratory rate
Papilledema

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

One of the first signs of head trauma is fever.

True or false

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Investigations

Indications for a skull X-ray:

Focal impact to head
Boggy swelling to head (potential depressed skull fracture)

CT Scan
C-spine CT
MRI
Blood test:

FBC
Coagulation profile
UEC
Blood glucose level (BGL)
Venous blood gas
LFT + Lipase (if abdominal trauma)
Group and hold or cross match

Government of Western Australia: Child and Adolescent Health Services, July 2022

Contact info: info@nursesinternational.org

Indication of CT Scan:

Focal neurological deficit
Depressed skull fracture
Deterioration in GCS of more than 2 points
Penetrating skull injury
Possible basal skull fracture
Post traumatic seizure with no history of epilepsy
Suspicion of open or depressed skull injury or tense fontanelle
Clinical suspicion of non-accidental injury
Age < 1 year: presence of bruising, swelling or laceration > 5 cm on the head

Two or more of the following:

LOC > 5 minutes
Abnormal drowsiness
More than 3 vomits (discrete episodes)
Amnesia (antegrade or retrograde) lasting > 5 minutes
Dangerous mechanism of injury:

high speed MVA – either as pedestrian, cyclist or vehicle occupant
fall from > 3 metres
high speed injury from a projectile or an object
bleeding tendency

Indications for c-spine CT:

GCS < 13 on initial examination
Intubated
Focal neurological signs
Paresthesia on upper limb or lower limb
Strong clinical suspicion despite normal X-ray
Plain X-ray difficult to take or inadequate
Plain X-rays abnormal
Definitive diagnosis of cervical spine injury needed (e.g. before surgery).

Hyperglycemia after traumatic brain injury has also been associated with patient's outcome. Cochrane et al. reported that GCS score and serum glucose levels were independent predictors of mortality in children. In this study, serum glucose level greater than or equal to 300 mg/dL at admission was uniformly associated with death.[20] Inability for normalization of glucose blood levels within 48 hours has also been associated with worse prognosis.

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Management

Mild head injury

ABCs must be assessed before any detailed history-taking or neurologic examination
Observe for 2-4 hours in ED if there is clinical concern
Most can be discharged home with the Head Injury - Health Fact sheet

Government of Western Australia Child and Adolescent Health Services, July 2022

Contact info: info@nursesinternational.org

Instructions to Parents or Caregivers for Observation at Home of Children and Adolescents with Head Trauma

Bring child back to clinic immediately if any of the following signs and symptoms appear within the first 72 hours after discharge:

Any unusual behaviour
Disorientation as to name and place
Problems with balance
Worsening headache
Seizures
Difficulty seeing, hearing, speaking or walking
Unusual drowsiness or hard to wake up
Vomiting more than two or three times
Pupils are unequal and/or do not react to light
Blood or clear fluid running from ears or nose

Instructions to Parents or Caregivers for Observation at Home of Infants and Young Children with Head Trauma

Bring child back to clinic immediately if any of the following signs and symptoms appear within the first 72 hours after discharge:

Poor feeding
Vomiting more than two or three times
Unusual drowsiness or hard to wake up
Bulging fontanel
Any unusual behaviour

Source: Adapted from Children's Hospital of Eastern Ontario. Emergency care orientation manual. (2004). Minor Head Injury Discharge Instructions handout.

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Management

Moderate head injury

CT if indicated
Admit to ED Short Stay Unit
Neurological observations half hourly until GCS = 15, then hourly thereafter
Consider head CT if:

persistent headache
persistent vomiting, drowsy
new neurological signs
deteriorating GCS

Discharge if child remains stable

Government of Western Australia: Child and Adolescent Health Services, July 2022

Contact info: info@nursesinternational.org

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Management

Severe head injury: Aim to prevent secondary injury to the brain

Treatment for:

Hypoxia

Intubate (continue C-spine precautions)
Keep ETCO2 35-40
SpO2 100%
Keep head in midline at 30 degrees (Head and neck in midline)
Minimize stimuli (suctioning and movement)
Consider cooling

Government of Western Australia Child and Adolescent Health Services, July 2022

Government of Canada, 2012

Contact info: info@nursesinternational.org

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Management

Severe head injury:

Hypotension

0.9% saline bolus of 20 mL/kg (as required)
Consider inotrope infusion

Raised Intracranial Pressure

Hypertonic 3% saline: 3mL/kg as a slow IV push
Mannitol 20% solution: 0.5 - 1g/kg (2.5 - 5 mL/kg) IV over 20 minutes
Hyperventilation to decrease ETCO2: 35-40

Seizures:

Load with Phenytoin 20mg/kg over 30 minutes

Government of Western Australia Child and Adolescent Health Services, July 2022

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

Why is it important to control seizures in the presence of a head injury?

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Nursing Management

Assessment:

Airway, Breathing and Circulation (ABC)
Neurological evaluation
Examination of vital signs
Level of consciousness
Cues for Increased Intracranial pressure
Check nose and ear for CSF leak
Observation of seizures
Pain assessment
Drainage from any orifice (Bleeding from ear suggests the possibility of basal skull fracture)

Shaikh, Waseem, & Boling, 2021

Hockenberry, & Wilson, 2007

Contact info: info@nursesinternational.org

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Nursing Management

Provide a safe environment (side rails up)

(If the child is extremely restless, a hard surface may be padded and restraints used to prevent further injury)

Keep head in midline at 30 degrees (Head and neck in midline)
Maintain adequate ventilation, oxygenation and circulation
Open IV line
Administer medications as prescribed
Pain management
Emotional and education support to family

Shaikh, Waseem, & Boling, 2021

Hockenberry, & Wilson, 2007

Contact info: info@nursesinternational.org

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Nursing Alert

Stabilize the spine after head injury until spinal cord injury is ruled out.
Children with a subdural hematoma and retinal hemorrhage should be evaluated for possibility of child abuse (Shaken baby syndrome).
Post-traumatic meningitis suspected in children with increasing drowsiness and fever who have basilar skull fracture.
Suctions through the nares is contraindicated because the risk of the catheter entering the brain through a fracture in the skull.

Hockenberry, & Wilson, 2007

Contact info: info@nursesinternational.org

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

An infant is admitted with a retinal hemorrhage.

What assessment should the nurse consider?

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Red Flags

If a child loses consciousness or vomits more than three times , medical attention should be sought.

Infant with a retinal hemorrhage and subdural hematoma should be assessed for shaken baby syndrome.

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur
Health customs: In some cultures family members play a large role in health care decision-making
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations

AHRQ, 2020

Contact info: info@nursesinternational.org

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may effect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Government of Canada. (2012). Clinical Practice Guidelines for for Nurses in Primary Care- Pediatric and Adolescents Care. https://www.canada.ca/en/indigenous-services-canada/services/first-nations-inuit-health/health-care-se rvices/nursing/clinical-practice-guidelines-nurses-primary-care/pediatric-adolescent-care.html

Government of Western Australia Child and Adolescent Health Service. (2022 July). Head Injury.https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Head-injury

Hockenberry, M. J. & Wilson, D. (2007). WONG’S Nursing Care of Infants and Children. 8th edi. Mosby

Contact info: info@nursesinternational.org

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References

Shaikh, F., Waseem, M.,& Boling, A.M. (2021 Nov 7).Head Trauma (Nursing) . StatPearls Publishing. Available from: https://www.ncbi.nlm.nih.gov/books/NBK568699/

Stanford Children’s Health. (2022). Head Injury in Children. https://www.stanfordchildrens.org/en/topic/default?id=head-injury-in-children-90-P02604

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