NCM 109 : PEDIA LECRURE

HYDROCEPHALUS & BURNS

TI-AD, ANGELYN E. 2nd Semester - FINALS | BSN-2A A.Y. 2023-2024
CI: Naneth G. Oida

HYDROCEPHALUS AND BURNS - Hydrocephalus is the accumulation of an

excess amount of CSF in the ventricles on the

HYDROCEPHALUS
- Is derived from the Greek word “hydro” –
meaning water and “cephalus” meaning
the head.

- Is a common disorder of the CSF physiology

resulting in abnormal expansion of the cerebral
ventricles.

- Is the buildup of fluid in the cavities (ventricles)

deep within the brain.

- Cerebrospinal fluid (CSF) is a clear

colorless plasma-like fluid that bathes the subarachnoid space.
central nervous system (CNS)
- Hydrocephalus is thought to result from
- Cerebrospinal fluid circulates through a system aqueductal stenosis (narrowing of
of cavities found within the brain and spinal aqueductal – preventing from exiting the
cord; ventricles, subarachnoid space of the ventricles) and blockage of the CSF outflow
brain and spinal cord and the central canal of from the fourth ventricle.
the spinal cord.

- Because cranial sutures are not firmly fused in

infants, the pressure of this excess fluid
causes enlargement of their skull.

- Cerebrospinal fluid formed in the lateral

ventricles flows through the paired
interventricular foramina (foramen of Monro)
into the third ventricle, then through the
mesencephalic aqueduct (aqueduct of Sylvius)
into the fourth ventricle.
- If
fluid
- The majority of CSF exits from the fourth
is
ventricle into the subarachnoid space; a
able
small amount may enter the central canal of
to
the spinal cord
reach the spinal cord, the disorder is called a
communicating or extra-ventricular

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 hydrocephalus.
- If there is a block to the CSF so that it cannot
circulate into the subarachnoid space, the
disorder is termed obstructive or
intraventricular hydrocephalus or
noncommunicating hydrocephalus
Hydrocephalus can occur at
1. birth (congenital) or
2. from an incident later in life (acquired).
- Although the increased fluid may occur in
isolation, 90% of babies with congenital
hydrocephalus have a diagnosis of
meningomyelocele (spinal cord, meninges, spinal
nerves – affected part)
PREVALENCE
- Hydrocephalus is the most common disease
treated by pediatric neurosurgeons and
accounts for roughly $2 billion in health
expenditures in the United States every year.
- The prevalence of infant hydrocephalus is
roughly one case per 1,000 births, but this is
probably greater in developing countries.
- Hydrocephalus diagnosed at birth occurs in
approximately 78 per 100,000 births in
developed countries and 106 per 100,000
births in low- and middle-income countries .
- A preterm infant, less than 24 weeks gestation,
may have acquired hydrocephalus from an
intraventricular hemorrhage. The degree of
blockage is directly related to the quantity of
intraventricular blood, which blocks the
passage of CSF – capillaries are not matured
3 main reasons explain why CSF accumulates:
Three main reasons explain why CSF accumulates:
1. Overproduction of fluid by the choroid plexus
in the first or second ventricle as could occur
from a growing tumor (rare)
2. Obstruction of the passage of fluid in the
narrow aqueduct of Sylvius (the most
common cause) or the foramina of Magendie
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and Luschka, the openings that allow fluid to
leave the fourth ventricle.
Hemorrhage from trauma, a growing tumor, or
infections such as toxoplasmosis, meningitis,
or encephalitis may leave adhesions behind
that block fluid flow at these points.
- Arnold-Chiari disorder (elongation of the
lower brain stem and displacement of the
fourth ventricle into the upper cervical canal)
and a
- Dandy-Walker cyst (a fluid-filled sack by one
of the ventricles in the brain) are still other
causes.
3. Interference with the absorption of CSF from
the subarachnoid space if a portion of the
subarachnoid membrane has been removed,
as occurs with surgery for a meningocele or
after extensive subarachnoid hemorrhage,
when portions of the membrane absorption
surface become obscured.
TYPES
TYPES
 Acquired Hydrocephalus: This is the type of
hydrocephalus that develops at birth or in
adulthood and is typically caused by injury or
disease.
 Congenital Hydrocephalus: It is present at
birth and may be caused by events that occur
during fetal development or as a result of
genetic abnormalities.
 Communicating Hydrocephalus: This type of
hydrocephalus occurs when there is no
obstruction to the flow of CSF within the
ventricular system. The condition arises either
due to inadequate absorption or due to an
abnormal increase in the quantity of CSF
produced
 Non-communication (Obstructive)
Hydrocephalus: It occurs when the flow of CSF
is blocked along one of more of the passages
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 connecting the ventricles, causing
enlargement of the pathways upstream of the
block and leading to an increase in pressure
within the skull.
 Normal Pressure Hydrocephalus: It is a form
of communicating hydrocephalus that can
occur at any age, but is most common in the
elderly. It is characterized by dilated ventricles
with normal pressure within the spinal column.
 Hydrocephalus Ex-vacuo: It primarily affects
adults and occurs when a degenerative
disease, like Alzheimer's disease, stroke or
trauma, causes damage to the brain that may
cause the brain tissue to shrink.
MANIFESTATIONS
- The symptoms of hydrocephalus tend to vary
greatly from person to person and across
different age groups.
- Infants and young children are more
susceptible to symptoms from increased
intracranial pressure like vomiting and adults
can experience loss of function like walking or
thinking
ASSESSMENT
- With an obstruction present, excessive fluid
accumulates and dilates the system forward of
the point of obstruction.
- If the atresia is in the aqueduct of Sylvius, the
first, second, and third ventricles will dilate.
- If it is at the exit from the fourth ventricle, all
ventricles will dilate. Symptoms may develop
rapidly or slowly depending on the extent of
the atresia.
- Hydrocephalus detected in utero through a
prenatal sonogram may be shunted prior to
birth, particularly if it is associated with a
meningomyelocele
- During the first few weeks of life, the infant's
fontanelles widen and appear tense, the suture
lines on the skull separate, and the head
diameter enlarges. As the fluid accumulation
continues, the scalp becomes shiny and scalp
veins become prominent
- The brow bulges forward (bossing) and the
eyes become "sunset eyes" (the sclera
shows above the iris because of upper lid
retraction).
- Infants begin to show symptoms of increased
intracranial pressure, such as decreased pulse
and respirations, increased temperature and
blood pressure, hyperactive reflexes,
strabismus, and optic atrophy
- Irritable
- Lethargic
- with a typical shrill, high-pitched cry
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To best detect hydrocephalus:
- measure the head circumference of all
newborns within an hour of birth and again
before discharge from the health- care facility
to establish a baseline.
- All children younger than 2 years should
then have their head circumference
recorded and plotted on an appropriate
growth chart at all healthcare visits so that
the child whose head is growing
abnormally can be detected
- As the head continues to enlarge, the infant's
motor function becomes impaired because of
both neurologic impairment and atrophy
caused by the inability to move such a heavy
head
- Hydrocephalus can be demonstrated by
ultrasound, computed tomography (CT), or
MRI.
- A skull X-ray film will reveal the separating
sutures and thinning of the skull.
- Transillumination will reveal that the skull is
filled with fluid rather than solid brain tissue
THERAPEUTIC MANAGEMENT
THERAPEUTIC MANAGEMENT
The treatment for hydrocephalus depends on its cause
and extent.
 acetazolamide (Diamox)
o overproduction of fluid
o a diuretic, may be prescribed to
promote the excretion of this excess
fluid
 ventricular endoscopy
o destruction of a portion of the choroid
plexus
if a tumor in that area is responsible for the
overproduction of fluid, removal of the tumor should
provide a solution
 Hydrocephalus is usually caused by
obstruction, so the treatment for children who
do not have other neural tube involvement
(such as a meningomyelocele) usually
involves laser surgery to reopen the route of
flow or bypassing the point of obstruction by
shunting the fluid to another point of
absorption
 ventriculoperitoneal shunt
o is a thin plastic tube that helps drain
extra cerebrospinal fluid (CSF) from
the brain
PROGNOSIS
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PROGNOSIS
- The prognosis for hydrocephalus depends on
the cause, the extent of symptoms and the
timeliness of diagnosis and treatment.
- Some patients show a dramatic improvement
with treatment, while others do not.
- In some instances of normal pressure
hydrocephalus, dementia can be reversed by
shunt placement.
- Other symptoms, such as headaches, may
disappear almost immediately if the symptoms
are related to elevated pressure.
- In general, the earlier hydrocephalus is
diagnosed, the better the chance for
successful treatment.
- The longer the symptoms have been present,
the less likely it is that treatment will be
successful.
- Unfortunately, there is no way to accurately
predict how successful surgery will be for each
individual.
- Some patients will improve dramatically, while
others will reach a plateau or decline after a
few months
Surgical Intervention:
- Shunt placement: This is the most common
and effective treatment for hydrocephalus.
- A shunt is a thin tube system implanted to
divert excess CSF from the ventricles. The
other end of the shunt is placed in another part
of the body, typically the abdomen (peritoneal
cavity), where the CSF can be safely absorbed
Endoscopic third ventriculostomy (ETV):
- This procedure creates a new opening in the
floor of the third ventricle. This allows CSF to
flow naturally back into the subarachnoid
space for reabsorption, bypassing the
blockage
- is a minimally invasive approach compared to
shunt placement.
Lumbar puncture (LP):
- In specific cases, like hydrocephalus following
intraventricular hemorrhage (IVH) in newborns,
repeated LPs can be used to drain CSF and
potentially allow for spontaneous CSF
resorption if the protein content in the CSF is
low
Medications
 Diuretics like furosemide
o used to increase urine output and
potentially reduce CSF production.
o However, this approach requires close
monitoring of electrolytes and overall
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fluid balance due to potential side
effects
BURNS
BURN
Key facts
- An estimated 265 000 deaths every year are
caused by burns - the vast majority occur in
low- and middle-income countries.
- Non-fatal burn injuries are a leading cause of
morbidity.
- Burns occur mainly in the home and
workplace.
- Burns are preventable.
DEFINITIONS
• are injuries to tissue caused by excessive heat greater
than 40°C
• is defined as destruction found in the epidermal tissue,
dermal tissue, or deeper tissues, due to contact with
thermal, chemical, or electrical agents.
• are the second most common unintentional injuries
seen in children 1-4 years old and the third most
common cause in children 5-14 years of age.
• According to CDC (2016), every day, there are more
than 300 children treated in emergency rooms for burn
related injuries.
• Younger children are most at risk for scald burn that are
caused by hot liquid or stream.
• Older children are more apt to be burned from flames
after they move too close to a campfire, heater or
fireplace, touch a hot curling iron or play with matches
or lighted candles.
•Burn injuries tend to be more serious in children than
in adults because the same size burn covers a larger
surface of a child's body
TO PREVENT
PREVENT
 Be "alarmed"
 Have an escape plan.
 Cook with care
 check water heater temperature
BURN SAFETY OUTDOORS
BURN SAFETY OUTDOORS
 Watch grills, fire pits and camp fires
 Check car seats
 Avoid backyard fireworks
 Hide matches
 Be careful with candles
 Take care with cigarettes
 Use space heater wisely
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COMMON CAUSES OF BURNS - barrier to infection
COMMON CAUSE OF BURNS - protection from external injury
1. Thermal Burns - temperature control
2. Radiation Burns - control of the body fluids
3. Chemical Burns - sensory organ
4. Electrical Burns - determine identity
5, Cold Burns/ Frostbites
ASSESMENT RULE OF NINE
ASSIFICATION OF BURNS
First questions must ask:  First degree
 Second degree
• Where is the burn?  Third degree
 Fourth degree
• What are its extent and depth?

Along with the size and depth, be certain to assess and

document the location of the burn.

Examples:
1. Face and throat- are particularly hazardous because they
may be accompanying but unseen burns in the respiratory
tract that could lead to respiratory tract obstruction.

2. Hand burns are also hazardous because if the fingers and

thumb are not position properly during healing, adhesions
will inhibit full range of motion in the future.

3. Burns of the teeth carry a high-risk secondary infection.

4. Genital burns are also hazardous because edema of the

urinary meatus may prevent child from voiding

RULE OF NINE FIRST DEGREE

- used in adults - redness, swelling, affected part is epidermis

- is a quick method of testing the extent of burn - Involves the epidermis or outer layer of skin.
- does not always apply in children because the body - Appears reddened, dry, and feels mildly painful.
proportion of children is different from those of adults and - Heals by simple regeneration so takes 1-10 days to heal.
misleading in the very young child. - back in color for months

✓ 9%: head back, chest and abdomen, front and back SECOND DEGREE
legs, front and back thighs
✓ 18% Posterior trunk - type A: redness, blister, superficial dermis
✓ 4.5%: arms and hands, - type B: pallor, blister, pain, partial dermis
✓ 1%: genitals
- Involves the epidermis and part of the dermis layer of skin.
✓ 18% Posterior trunkLECTURE NCM 109| MATERNAL AND
- Appears red, blistered, and may be swollen.
CHILD HEALTH NURS
- Very painful. Heals by regeneration of tissue over 2- 6
weeks.

THIRD DEGREE
- Greyish white or black necrosis analgesia, complete dermis
- Involves the epidermis and full extent of the dermis.
- Appears white or charred and lacks sensation as the nerve
endings are destroyed.
- Skin grafting is usually necessary, and healing takes
months.
- Scar tissue will cover the final healed site.

STRUCTURES OF THE SKIN FOURTH DEGREE

NG AT RISK (PEDIA) STRUCTURE OF THE SKIN
LAYER OF THE SKIN: - carbonization
- Hair follicle - Full-thickness burn extending into muscle or bone.
- epidermis - Skin grafting is necessary; muscle and bone may be
- dermis permanently damaged; scarring will cover the healed site.
- subcutaneous fat AN

FUNCTIONS OF THE SKIN

Emergency Management for Minor Burns

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GEMENT
- All burns, including minor burns, need immediate
care because of the potential pain involved
- Although minor burns (typically first- degree partial
thickness burns) are the simplest type of burn, they
involve pain and death of skin cells and therefore
must be treated seriously.
- Be certain that parents have a follow-up appointment
in about 2 days to have the dressing changed and the
area inspected for a secondary infection.
- Caution parents to keep the dressing dry (no
swimming or getting the area wet while bathing until
the burn is healed about 1 week).
Emergency Management for Moderate Burns
- Moderate or second-degree burns typically are blistered.
- Do not rupture these blisters because doing so denudes the
site and invites infection.
- The burn should be covered with a topical antibiotic
such as silver sulfadiazine and a bulky dressing to
prevent damage to the burned site and promote healing.
- The child usually is asked to return in 24 hours to assess
that pain control is adequate and there are no signs and
symptoms of infection.
- Broken blisters may be debrided (cut away) to remove
possible necrotic tissue as the burn heals.
Emergency Management for Severe Burns
- The child with a third degree or fourth degree burn is
critically injured and requires immediate care.
- Sure care, including fluid therapy, systematic antibiotic
therapy, pain management and physical therapy.
- The goal is to prevent disability caused by scarring,
infection, or contractures.
Emergency Management for Electrical Burns of
the Mouth
- If a child puts the prongs of a plugged-in extension
cord into the mouth or chews on an electric cord, the
mouth can be burned severely.
- When electrical current from a plug is conducted for
a distance through the skin and underlying tissue it can
cause an ulcer.
- If blood vessels were burned active bleeding from the
lesion will be present.
- Most children with electric burns are admitted to an
observation unit for at least 24 hours because edema
in the mouth could lead to airway obstruction.
- Eating will be a challenge for the next week because
the child's mouth is so sore.
- Soft foods and fluids may be easiest to swallow.
- Electrical burns of the mouth turn black as local
tissue necrosis begins.
- They heal with white, fibrous scar tissue, possibly
leaving a deformity of the lips or cheeks and difficulty
speaking clearly afterward.L
- This can be minimized by using a mouth appliance,
which helps maintain lip contour.
THERAPY FOR BURNS
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• Second- and third-degree burns may receive
a) open treatment
- leaving the burned area exposed to the air, or
b) closed treatment
- the burned area is covered with an antibacterial cream and
many layers of gauze.
 As a rule, burn dressings are applied loosely for the first
24 hours to prevent interference with circulation as
edema forms.
 Be certain not to allow two burned body surfaces, such
as the sides of fingers or the back of the ears and the
scalp, to touch, because, as healing takes place,
webbing will form between these surfaces.
 Do not use adhesive tape to anchor dressings to the
skin; it is painful to remove and can leave excoriated
areas, which provide additional entry sites for infection.
 Netting is useful to hold dressings in place because it
expands easily and needs no additional tape.
TOPICAL THERAPY
 If a topical cream is not effective against invading
organisms in the deeper tissue under the eschar, daily
injections of specific antibiotics into the deeper layers of
the burned area may be necessary.
 If a burned area, such as the female genitalia, cannot
be readily dressed, the area can be left exposed. The
danger of this method is the potential invasion of
pathogens.
ESCHAROTOMY
 is defined as the surgical incision through the eschar
into the subcutaneous tissues to allow the extremity to
continue to swell without compressing the underlying
blood vessels
 As natural protection for a burned arca, a rigid scab (an
eschar) forms over moderately or severely burned
areas.
 Fluid accumulates rapidly under an eschar, putting
pressure on underlying blood vessels and nerves.
 If an extremity or the trunk has been burned so that
both anterior and posterior surfaces both have eschar
formation, a tight band may form around the extremity
or trunk, cutting off circulation to distal body portions.
 If distal parts feel cool to the touch and appear pale,
any tingling or numbness is present, pulses are difficult
to palpate, and capillary refill is slow (longer than 5
seconds), an escharotomy (cut into the eschar) may be
performed (Kupas & Miller, 2010)
 Some bleeding will occur after escharotomy. Packing
the wound and applying pressure usually relieves this.
DEBRIMENT
 the removal of necrotic tissue on which microorganisms
could thrive from a burned area to reduce the possibility
of infection
 This may be done using collagenase (Santyl), an
enzyme that dissolves devitalized tissue, or manually.
 For manual debridement, children may have 20 minutes
of hydrotherapy beforehand to soften and loosen
eschar, which then can be gently removed with forceps
and scissors.
 Debridement is painful, and some bleeding occurs with
it.
 Premedicate the child with a prescribed analgesic and
help the child use a distraction technique during the
procedure to reduce the level of pain.
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 Transcutaneous electrical nerve stimulation (TENS)
therapy ог patient-controlled analgesia also can
behelpful pain management measures.
 If burned areas are debrided in this manner day after
day, granulation tissue forms underneath.
 When a full bed of granulation tissue is present (about 2
weeks after the injury), the area is ready for skin
grafting.
 In some burn centers, this waiting period is avoided by
immediate surgical excision of eschar and placement of
skin grafts.

GRAFTING
GRAFTING
Skin grafting
- is a surgical procedure that involves removing skin from
one area of the body and moving it, or transplanting it, to a
different area of the body.
- can be from animals or other people skin

Allografting
- the placement of skin (sterilized and frozen) from cadavers
or a donor on the cleaned burn.
- These grafts do not grow but provide a temporary
protective covering for the area.
- In small children, xenografts, or skin from other
sources,such as porcine (pig) skin, may be used.

Autografting
- is a process in which a layer of skin of both epidermis and
a part of the dermis (called a split- thickness graft) is
removed from a distal, unburned portion of the child's body
and placed over the prepared burn site, where it will grow
and replace the burned skin
- The advantage of both types of grafting is that they reduce
fluid and electrolyte loss, pain, and the chance of infection.
- Skin for a split-thickness graft is removed from the buttocks
or inner thigh under general anesthesia.
-Large burn areas mayreuire mesh grafts ( a strip of partial
thicknes skin is slit at intervals so that it can be stretched to
cover a larger area.)
- Fish skin can be grafted onto burns. It recruits the body's
own cells and is converted into living tissue over time

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