CONGENITAL ANOMALIES & TRAUMATIC CONDITIONS

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CONGENITAL ANOMALIES & TRAUMATIC CONDITIONS
Hydrocephalus
  • Normal CSF amount: 150 mL
  • Normal CSF pressure (ICP): 10-15 mmHg
  • CSF has no red blood cells
  • CSF is produced by the choroid plexus, travels around the ventricular system and is reabsorbed by the subarachnoid villi
  • Causes and Associated Factors:
    • prematurity - ventricular system may be underdeveloped
    • gram (-) meningitis - causes inflammation and subsequent edema
    • aqueductal stenosis - a blockage in the Aqueduct of Sylvius, the passageway from the third to the fourth ventricle
    • head injury - may cause inflammation on the brain post-trauma
    • intracranial tumor - may impede flow of CSF depending on the area blocked
    • Arnold-Chiari malformation - congenital herniation of the cerebellar tonsils leading to a blockage of flow of CSF from the brain to the spinal cord
    • Dandy-Walker Syndrome - congenital absence of the the cerebellar vermis and an increased size of the fourth ventricle, increasing pressure on the brain
    • myelomeningocele - neural tube defect which forms a sac on an unclosed area of the spine causing increased pressure of CSF
  • Types
    • Communicating - caused by decreased absorption of the subarachnoid villi
    • Non-communicating - impediment of CSF flow within the brain's ventricular system
  • Signs and Symptoms
    • increased head circumference
    • bulging fontanels
    • dilated scalp veins
    • separated skull sutures
    • MacEwen's Sign (crackpot sound upon percussion)
    • sluggish pupillary reflexes
    • increased ICP
    • change in level of consciousness
    • setting sun sign - also called sunset eyes; a downward deviation of the eye, such that you can see the sclera in between the iris and the upper eyelid
    • high pitched cry
  • Diagnostic Tests
    • CT scan - to check for bones and other hard tissue (e.g. tumors) blocking the ventricular system
    • MRI - to check for soft tissue deformities (e.g. cysts, stenosis)
    • daily measurement of head circumference
  • Treatment
    • removal of tumor
    • shunting - diversion of flow of CSF to another body area where it is reabsorbed
      • ventriculoperitoneal - from a ventricle to the peritoneum
      • ventriculoatrial - from a ventricle to the heart's atrium
      • lumboperitoneal - from the lumbar area of the spine to the peritoneum
      • ventircular pleural - from a ventricle to the pleural space
      • ventricular bypass - from one ventricle to another
      • Complications:
        • infection
        • malfunction - obstruction or dislodged shunting catheter
    • PreOp
      • avoid increasing ICP
        • AVOID sneezing, coughing, straining, Valsalva reflex
        • DO NOT occluding the carotid artery
        • hips slightly flexed and legs abducted
        • support the neck muscles
        • fluid restrictions
        • administer stool softeners
        • place sheep skin or lamb's wool under head for support
      • change positions q2h
      • small frequent feedings up until NPO
    • PostOp
      • avoid increasing ICP (see above)
      • frequent neurologic assessment
      • pain relievers as ordered
      • antibiotics as ordered
      • emotional support
      • position on the unoperated side
      • monitor for changes
Spina Bifida
  • the higher the deformity, the more neurologic deficits presented
  • Types
    • Spina Bifida Occulta - not visible externally
      • manifests with a skin dimple, port-wine nevi (wine-colored strained skin), tufts of hair, of subcutaneous lipoma (fat despoit)
    • Spina Bifida Cystica - with an external sac-like protrusion
      • Meningocele - protrusion of the meninges and CSF; (+) transillumination
      • Myelomeningocele - protrusion of the meninges, CSF, and nerves; (-) transillumination
  • Diagnostic Tests
    • fetal ultrasound
    • increased alpha-fetoprotein (16-18 weeks)
    • chorionic villi sampling (9 weeks)
    • MRI, CT, myelography (visualization of the flow of CSF in the spine)
    • transillumination
  • Treatment
    • surgical closure within 1st 72 hours of life
    • open fetal surgery
    • PREVENTION: FOLIC ACID (0.4-4 mg/day during pregnancy)
    • shunting
    • prone position at rest
    • side-lying position when feeding
    • apply sterile dressing with NSS on area
    • avoid increased ICP (see above)
Neurogenic Bladder Syndrome 
  • dysfunction of the urinary bladder due to spinal cord disease, injuries, and defects (e.g. spina bifida)
  • Signs and Symptoms
    • difficulty or complete inability to urinate
  • Treatment
    • intermittent catheterization
    • vesicostomy - stoma creation on the abdominal wall and urinary bladder to provide for drainage
    • urinary diversion - construction of a new urinary bladder from bowel/stomach
    • oxybutynin (Ditropan) - improves bladder control and storage
    • augmentation enterocystoplasty - improves bladder capacity
Cerebral Palsy
  • Types
    • Spastic - most common; hypertonicity of muscles, impaired motor skills
    • Dyskinetic/Athetoid - may be caused by kernicterus (high unconjugated bilirubin at birth leading to brain damage); athetoid movements (slow, writhing, wormlike movements), drooling, dysarthria (poor articulation of words, "bolol-bolol"), poor motor skills
    • Ataxic - may be caused by damage to cerebellum; poor motor skills, wide based gait, tremors
    • Mixed/Dystonic - a mix of spastic and athetoid
  • Causes
    • cord coil
    • intrauterine hypoxia
    • birth trauma
    • intrauterine infection, radiation exposure
    • multiple births
  • Treatment
    • foot orthoses/braces - remedies fait problems
    • rhizotomy - surgical release of nerves causing spasticity
    • baclofen & botox injections - relieves spasticity
    • stretching exercises
    • seizure precautions
    • promote safety
      • use sturdy, padded furniture
      • side rails up
      • wear helmets
      • use safety restraints as needed
      • avoid polished floors
    • talk slowly
    • encourage participation during self care
    • encourage activities that improve manual dexterity - drawing, writing
    • PATIENCE
Skull Fractures
  • Types
    • Linear Skull Fracture - linear crack on the skull
    • Comminuted/Depressed Skull Fracture - fractured area of skull breaks into pieces and are displaced inward; usually occurs from blunt force trauma e.g. rock to head, baseball bat to head, hammer to head
    • Basillar Skull Fracture - fracture of the bones at the base of the skull
  • Signs and Symptoms
    • halo sign - blood stain surrounded by yellowish stain (indicative of CSF leakage)
    • raccoon eyes - periorbital ecchymosis
    • Battle's Sign - bruising behind the ear (for basillar skull fracture)
    • blood in the sinuses
    • bleeding from the ears or nose
  • Injury Types
    • Coup Injury - at point of impact (hits forehead on wheel after MVA)
    • Contracoup Injury - at opposite side of impact (hits back of head to headrest after MVA)
    • Primary Injury - impact damage (bruising on forehead)
    • Secondary Injury - delayed events that follow injury (edema, infection, hypoxia)
  • Emergency Management
    • log rolling technique
    • jaw thrust maneuver
    • immobilize head and neck (e.g. cervical collar)
    • decrease stimuli
Traumatic Brain Injury
  • Concussion - reversible; may have temporary change of level of consciousness, headache, and nausea and vomiting
  • Contusion - irreversible; actual damage to the brain
  • Closed - force from object damages brain but doesn't penetrate skull
  • Open - object penetrated the skull and into the brain
  • Signs and Symptoms:
    • altered levels of consciousness
    • loss of reflexes
    • pupillary abnormalities
    • neurologic deficits
    • change in vital signs
    • sensory dysfunction
    • headache
    • vertigo
    • seizures
  • Management
    • evacuation of clots
    • mannitol - to reduce ICP
    • phenytoin - for seizures
    • analgesics
    • monitor neurologic vital signs
    • quiet environment
    • wound care
    • fluid regulation
    • ventilatory support
  • Complications:
    • Intracranial Hemorrhage
      • Epidural - blood collecting in between the dura and the skull
      • Subdural - blood collecting in between the dura and the brain
      • Intracerebral - blood collecting within the brain
    • Diffuse Axonal Injury - disconnection of axons within the brain; patient immediately after the injury becomes comatose, decorticate, or decerebrate
Spinal Cord Injuries
  •  Types
    • Incomplete - only part of the spinal cord is damaged
    • Complete - damage to an entire area of the spinal cord; may results in paraplegia (paralysis of lower extremities) or quadriplegia (paralysis of all extremities)
  • Effects of Injuries
    • Central Cord Syndrome
      • motor deficits, bowel and bladder dysfunction
      • injury to the central area of the spinal cord
    • Anterior Cord Syndrome
      • motor deficits, loss of sensation
      • injury to the anterior area of the spinal cord or blockage of the anterior spinal artery
    • Lateral Cord Syndrome (Brown-Sequard Syndrome)
      • ipsilateral loss of sensation and paralysis (left side injured, right side manifestations)
      • damage to half of the spinal cord transversely
    • Autonomic Dysreflexia
      • overstimulation of the ANS after injury
      • BP > 200mmHG, diaphoresis, bradycardia, restlessness, bowel and blader distention, facial flushing, cognitive impairment
    • Carpal Tunnel Syndrome - compression of the median nerve of the wrist from inflammation of the carpal tunnel; caused by repetitive movements of the wrist; symptoms include numbness and pain of the hand affected, muscle atrophy, and loss of grip strength
    • Sciatica - injury to the sciatic nerve resulting in pain to the lower extremity
  • Management
    • emergency care
      • immobilization
      • spinal/back board
      • patient must always be in an extended position
      • patient must be twisted or flexed
    • methylprednisolone - improves sensory and motor deficits
    • surgery


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notes.nursium.com: CONGENITAL ANOMALIES & TRAUMATIC CONDITIONS
CONGENITAL ANOMALIES & TRAUMATIC CONDITIONS
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https://notes.nursium.com/2017/03/congenital-anomalies-traumatic.html
https://notes.nursium.com/
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