Chapter 27: Cerebral Dysfunction: Injury, Infection & Seizures

Cerebral Dysfunction: Injury, Infection & Seizures details the compensatory mechanisms available to infants, such as open fontanels and suture expansion, compared to the limited capacity for compensation in older children, while outlining the progression of clinical manifestations from subtle signs like irritability to late signs such as Cushing triad and pupil dilation. A significant portion of the text focuses on neurologic assessment, utilizing the pediatric Glasgow Coma Scale (GCS) to evaluate eye opening, verbal response, and motor response, alongside the assessment of vital signs, posturing (decorticate and decerebrate), and reflexes to determine the level of consciousness (LOC) and potential brainstem involvement. The chapter reviews essential diagnostic procedures, including lumbar puncture, electroencephalogram (EEG), CT, and MRI, which are vital for identifying pathologies like tumors, hemorrhages, or infections. Nursing care for the unconscious child is extensively covered, emphasizing airway management to prevent hypoxia and hypercapnia, ICP monitoring via ventricular or epidural sensors, and the maintenance of fluid and electrolyte balance to prevent cerebral edema or syndromes like diabetes insipidus and SIADH. The discussion extends to traumatic brain injuries (TBI), differentiating between concussions, contusions, and fractures, and detailing the pathophysiology of epidural and subdural hematomas resulting from arterial or venous bleeding. Submersion injuries are addressed with a focus on hypoxia and aspiration pneumonia. The chapter also provides a thorough analysis of intracranial infections, specifically bacterial meningitis, identifying key pathogens like Streptococcus pneumoniae, clinical signs such as nuchal rigidity and positive Kernig and Brudzinski signs, and the critical need for isolation and antibiotics. Other conditions such as encephalitis, rabies, and Reye syndrome—a metabolic encephalopathy associated with aspirin use—are also examined. A major section is dedicated to seizure disorders and epilepsy, classifying events into focal and generalized seizures (including tonic-clonic, absence, and atonic), and exploring management strategies ranging from antiepileptic drugs and the ketogenic diet to vagus nerve stimulation and surgery. The text concludes with an exploration of cerebral malformations, particularly hydrocephalus, describing its pathophysiology regarding cerebrospinal fluid (CSF) imbalance, clinical presentations like the setting-sun sign, and surgical treatment using ventriculoperitoneal (VP) shunts, along with the monitoring of potential complications like shunt malfunction or infection.