Neonatal Neurological and Neuromuscular System
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Transcript Neonatal Neurological and Neuromuscular System
Neonatal Neurological System
Susan L Hicks, RN
Nurse Manager, NICU
Madigan Healthcare System
Objectives
Discuss pathophys
Identify Neural Tube Defects and care
Discuss Seizures
Discuss Glucose Management
Discuss IVH’s
Discuss HIE
Central Nervous System
The most complex system in the human
brain
Early recognition of infants at risk for
neurological dysfunction is crucial for
long term outcomes of these infants
Development of the CNS
Neurolation
– 2-3 weeks gestation
Procencephalic--2-3 months
Neuronal proliferation 3-5 months
Organization 5 months gestation to 1
year after birth
Myelinization 8 months gestation to 1
year after birth
Spinal Defects
Occur during neurolation
3-4 weeks gestation
Folic Acid supplementation is decreasing
incidence
Anecephaly
Failure of neural tube to close in the
cranial area
1:1000 live births, decreasing with folic
acid supplementation
20% are alive at 1 week of age
Supportive care measures
Encephalocele
Failure of closure of the anterior neural tube
1:2000 live births
Can occur over any region of the spine, 75%
over occipital region
Contain very little or large amounts of neural
tissue not related to the size of the defect
Surgical closure with possibility of VP shunt
in the presence of hydrocephalus
Spina Bifida
Deformations in the closure of the neural
tube in the spine or vertebrae
Open or closed defects
Clinically vary- can have minimal
neuromuscular effects, to paraplegia or
quadriplegia with loss of bowel and
bladder control
Spina Bifida
4 types
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–
–
–
Closed Spina Bifida Occulta
Meningocele
Myelomeningocele
Myeloschesis
Closed Spina Bifida Occulta
pilonidal / sacral dimple or hair tuft
10-30% of general population
Little or no clinical significance
Meningocele
Cystic sac with meninges, but spinal cord
and nerve roots are in normal position
Excellent outcome following surgical
repair
Myelomeningocele
Cystic sac containing meninges, spinal
cord, and vertebral elements
Sac exposed on back and covered with
epithelium or a thin membrane
1:1000 births, decreasing with Folic Acid
supplementation
Most frequently in the lumbar region of
the spine
Myelominingocele
Treatment
–
–
–
–
stabilization
surgical correction
bowel and bladder care
range of motion/ flexed positioning
Outcome
– These infants are usually otherwise healthy
and outcome dependent on location and
severity of disease
Myeloschesis
Spinal cord is open and exposed
Most of these infants are stillborn
Nursing Care and Prep for
Transport
Keep infant off site (may cut donut)
Keep site with sterile drsg on
Monitor VS closely – especially
temperature
Give IVF, monitor glucose
Observe for change in neuro status
Transport as soon as possible.
Seizures
The most common sign of neurological
dysfunction in the neonatal period
A sign of underlying disease process
resulting in acute disturbances of the
brain
If left untreated can lead to permanent
Central Nervous System Damage
Seizures
Neonatal seizures are usually acute and
resolve within the first few weeks of life
.15 % of term and 22.7% of premature
infants experience neonatal seizures
Seizures result from excessive
simultaneous electrical discharge or
depolarization of neurons
Risk Factors for Seizures
Asphyxia
Metabolic disturbances
Intraventricular Hemorrhage
Infection
Congenital Anomalies
Seizures- Clinical Presentation
Because of immature brain organization
at birth, especially in premature infants,
the is an inability to propagate and
sustain generalized seizure activity
In neonates, especially premature infants,
the symptoms are subtle
Seizures- Clinical Presentation
Abnormal movement or alteration of tone
in the trunk and extremities
– clonic, tonic, bicycling or swimming, general
loss of tone
Facial, oral and tongue movements
– sucking, grimacing, twitching, chewing,
swallowing, yawning
Seizures- Clinical Presentation
Ocular Movements
– eye deviation, blinking staring
Respiratory
– apnea, usually accompanied by one of the
other subtle movements
– labored, irregular respirations
Seizures
Seizure type is difficult to differentiate in
newborns
It often mimics activity seen in the active
sleep state
Jitteriness or Seizures
Jitteriness Seizures
Stimulus Sensitive
Yes
No
Eye Deviation
No
Yes
Predominant Movement Tremors
Ceases with Passive
Flexion
Yes
Clonic, Rhythmic
Jerking
No
Seizures- Management
Treat underlying cause
Anticonvulsant- Phenobarbital (most
common)
– also dilantin, diazepam, lorazepam
Careful monitoring of serum toxicology is
crucial to prevent toxicity
Controversy exists in the literature over
how long to use anticonvulsant
medications in neonates
Seizures- Nursing Care
Assessment
– time of the beginning and end of abnormal
activity
– description of movements and areas involved
– respiratory status and color
– state
Hypoglycemia
May be seen as jittery infants (which
could just be immature neurological
system)
Anticipate which infants identified as “at
risk’ and will need close monitoring.
– SGA, LGA, Potential for Sepsis, Mag moms,
– Diabetic moms!
Hypoglycemia Management
Follow your hospital guidelines for d-stix
protocol.
Know acceptable blood glucose values
at your hospital
– <40 usually feed, then recheck?
– <20 automatically get IV ?
– Continues with problem then continuous
IVF?
Hypoglycemia
If treating with feeding, colostrum
excellent. Use of formula should be last
option.
If treating with D10: use 2ml/kg bolus
dosing.
Always recheck Dstix according to your
policies.
Intraventricular Hemorrhage
Capillary bed of the germinal matrix in
premature infants is immature
Neurological Autoregulation
– Maintains consistent cerebral blood flow
despite changes in systemic blood flow
– asphyxia and hypoxemia alter autoregulation
brain becomes a pressure passive system
Germinal Matrix
Intraventricular Hemorrhage
Risk of IVH
–
–
–
–
–
–
–
–
prematurity
PPV
Medications/ Volume expansion
hypercapnea
care giving events
suctioning
pain
high pressure ventilation
Intraventricular Hemorrhage
90% of IVH within the first 72 hours of
life
50% within the first 24 hours
Intraventricular Hemorrhage
Clinical signs
– unexplained drop in Hematocrit
– Decrease in BP support despite pressor
support
– full fontanel
– change in activity and state
– decreased tone
Grades of IVH
Grade 1
Subpendymal only
Grade 2
Extension into ventricles
Grade 3
Extension into dilated ventricles
Grade 4
Extension into the brain
parenchyma
Treatment of IVH
Indomethacin is used for IVH
prophylaxis in premature infants
Treatment includes cardiopulmonary
support, treatment of seizures, control of
pain, and possibly ventriculo-peritoneal
shunting or tapping
Outcome dependent of degree of IVH,
unilateral or bilateral, and whether the
bleed is resolved or develops PVL
Hypoxic/ Ischemic
Encephalopathy
2-4% of term infants
60% of very low birth weight infants
3 stages
Stage 1 HIE
Hyper-alert, hyperresponsive to
stimulation
Dilation of pupils, reactive
Scarce secretions
EEG within normal limits
Stage II HIE
Lethargic, Hypotonic, weak suck
Seizure activity frequent
Pupils constrictive and reactive
Periodic variable respiration
Critical period- either improve or
deteriorate
Stage III HIE
Unresponsive, comatose, seizures within
6-12 hours
Pupils unequal, variable reactivity
Absent or depressed reflexes
Mechanical ventilation is required
Survivors take days to months to improve
Feeding difficulties and neurological
abnormalities frequently develop
HIE
Outcomes
– 20-50% die during newborn period
– 17-75% with significant sequelea
– disappearance of abnormal neurologic signs
by 2 weeks offers good prognosis
Subgaleal Hemorrhage
Occurs when emissary veins are damaged
and blood accumulates in the potential
space between the galea aponeurotica
and the periosteum of the skull
Potentially life threatening injury
Subgaleal Hemorrhage
This space has no containing membranes
or boundaries, the subgaleal hematoma
may extend from orbital ridges to the
nape of the neck
There is a large potential space for blood
to accumulate, and the possibility of life
threatening hemorrhage
Subgaleal Hemorrhage
Subgaleal Hemorrhage
Subgaleal Hemorrhage
Clinical presentation
– Diffuse swelling of the head
– Signs of hypovolemic shock
pallor
hypotension
tachycardia
tachypnea
prolonged capillary refill time
Subgaleal Hemorrhage
Clinical presentation
– The symptoms may be present at delivery, or
may not become clinically apparent until
several hours or up to a few days following
delivery
Subgaleal Hemorrhage
Clinical presentation
– The swelling is usually diffuse, and shifts
depending on position, and indents easily
upon palpation
– In some cases, swelling is difficult to
distinguish from edema of the scalp
– Occasionally, the cranial findings are
unremarkable, and hypotension and pallor
are the dominant signs
Subgaleal Hemorrhage
Patient Care Management
– Close documentation of vital signs per policy
– Closely monitor any infant with signs of poor
perfusion following vacuum delivery
blood pressure
capillary refill time
pulses
heart rate
respiratory rate and effort
Subgaleal Hemorrhage
Document any findings, interventions,
and outcomes thoroughly
Follow hospital policy regarding
physician notification
Outcome
– Once infant has survived the acute phase,
recovery will occur in 2-3 week