Paediatric coma scales

Paediatric intracranial empyema: differences according to age

No recent studies are available which consider the epidemiology and outcome of paediatric intracranial empyema (PICE). We retrospectively studied all PICE cases admitted in our institution from 1993 to 2006. Outcome was assessed using the Glasgow Outcome Scale (GOS) at 24 months. Aetiology, clinical features, therapeutic considerations and risk factors of poor outcome were analysed according to age. Data from 38 patients were studied; 33/38 presented with subdural empyema (SDE) and 5/38 with extradural empyema (EDE); 10/38 were infants <1 year of age with SDE, all related to bacterial meningitis; 28/38 were children, with 23/28 showing SDE and 5/28 EDE. Oto-sinogenic infections were the main causes in children. All infants recovered completely as did children with EDE. However, two out of 23 children with SDE had permanent neurological deficit, already detected on admission, and one out of 23 died. Thirty-three out of 38 were operated; 16 of which underwent multiple surgical procedure because of recurrence. Burr hole was performed in six infants and craniotomy in one, while 21/23 children underwent burr hole or craniotomy. Burr hole was more often associated with recurrence. In children with SDE, factors associated with poor outcome were neurological deficit (p = 0.002) and cerebral herniation on CT scan (p = 0.02) on admission. In this study, we gained further insights into modern epidemiology of PICE by highlighting age-related aetiology, symptoms, treatment strategy, and outcome differences. Meningitis was the main aetiology in the infants and sinusitis was prevalent in children. Finally, early diagnosis by neuro-imaging investigations and timely and appropriate multidisciplinary treatment may offer the best chance of recovery.

Learning as a possible sign of non-reflective consciousness in persons with a diagnosis of vegetative state and pervasive motor impairment

A diagnosis of vegetative state represents a serious predicament, which basically precludes/minimizes rehabilitation perspectives. Reliability of the assessment approach in these situations is of paramount importance, but not easy to achieve. In recent studies, a learning assessment procedure has been suggested as a supplement in the diagnostic process and assessed with eight patients. The procedure involves an ABABCB sequence in which A represents baseline phases with no stimulation available, B intervention phases with stimuli delivered contingently on target responses, and C a control condition. This condition involves stimulation presented non-contingently. The patients' ability to associate responding with environmental stimuli and thus increase such responding during the B phases, and reduce it during the A and C phases, may be considered a sign of learning. Learning might be viewed as representative of forms of concrete knowledge and presumably basic levels of consciousness. Preliminary results indicate that (a) signs of learning may appear in patients with a previous diagnosis of vegetative state and (b) the presence of those signs may require a revision of their diagnostic label and a reappraisal of their rehabilitation perspectives.

Head injuries in children

School nurses play a crucial role in injury prevention and initial treatment when injuries occur at school. The role of school nurses includes being knowledgeable about the management of head injuries, including assessment and initial treatment. The school nurse must be familiar with the outcomes of a head injury and know when further evaluation is indicated. Developing a head injury protocol in the school setting is one strategy to make sure that all involved are able to consistently and effectively respond to a head injury and prevent a possible negative outcome. The combination of a protocol, nursing judgment, and best practices can ensure that all means are used to take care of children when a head injury is sustained. These strategies will help to increase the safety of children at school. A systematic approach to the management of these types of injuries is essential for preventing possible complications.