Neurologic Emergenciestssicu.weebly.com/uploads/1/7/8/0/17806209/neuro.pdf · 2018-11-08 · •Gloves are a standard approach. •Based on the procedure you are conducting and the

NEUROLOGIC EMERGENCIES

INTRODUCTION

Homework

While stroke is common in geriatric

patients, it may happen to anyone.

Stroke is the fifth leading cause of death Stroke is

the leading cause of adult

disability

Three of the top 15 causes of death are

neurologic in nature.

Two of the top 10 causes of death are

neurologic in nature.

STRUCTURE OF THE NERVOUS SYSTEM

Two major structures

• Brain

• Spinal cord

The brain is the body’s computer.

It controls breathing, speech, and all other body functions.

Responsible for fundamental functions


Central nervous system

• Thought

• Perception

• Feeling

• Autonomic body functions

Peripheral nervous system

• Communication between the brain and the body


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THE BRAIN IS DIVIDED INTO THREE MAJOR PARTS:

the brain stem,

the cerebellum, and

the cerebrum

THE BRAIN STEM

controls the most basic functions of the body, such as

• breathing,

• blood pressure,

• swallowing, and

• pupil constriction.

BRAINSTEM

Midbrain

• LOC

• Location of the reticular activating system (RAS), which

• controls arousal and consciousness

• Muscle tone and posture

Pons

• Respiratory pattern and depth

Medulla oblongata

• Pulse rate, blood pressure, and respiratory rate

THE CEREBELLUM

controls muscle and body coordination.

responsible for coordinating complex

tasks that involve many muscles, such as standing on one foot without falling,

walking, writing, picking up a coin.

THE CEREBRUM

located above the cerebellum, is divided down the middle into

the right and left cerebral hemispheres.

Each hemisphere controls activities on the opposite side of

the body.

THE BRAIN LOBES

occipital

• Vision and storage of visual memories

Parietal

• Sense of touch and texture and storage of tactile memories

Temporal

• Hearing and smell

• Language

• Storage of sound and odor memories

Frontal

• Motor cortex:

• Voluntary muscle control

• storage of spatial memorie

Prefrontal cortex:

• Judgment and prediction of consequences of a person’s actions,

• abstract intellectual functions

THE BRAIN

NEURONS AND IMPULSE TRANSMISSION

A neuron contains:

Cell body

Axon: projection extending toward another cell

Axon terminal: where neurotransmitters are made


Synapses: slight gap between each cell

Neurotransmitters: connects synapse to next cell

Relay electrically conducted signals


Axons

Many are coated with myelin.

Insulating substance that allows the cell to transmit its signal consistently

Increases the speed of conduction

PATIENT ASSESSMENT

The brain is sensitive to change in

• Temperatures

• Levels of Oxygen

•Glucose.

SCENE SIZE-UP

Standard precautions protect you from harmful organisms or environments.

• Gloves are a standard approach.

• Based on the procedure you are conducting and the likelihood of contamination

patient with neurologic symptoms may have meningitis.

When people use illegal drugs, weapons and crime are likely to be close at hand.

SCENE SIZE-UP

The patient’s location may place you in a

dangerous situation.

Assessment begins at dispatch.

Examine the scene as you approach.

Ensure that you have a way to remove yourself.

PRIMARY ASSESSMENT

Form a general impression.

Where is the patient?

In distress or pain?

Position?

Inside or outside?

Obvious injuries?

Environment?

Drug paraphernalia?

Living conditions?

Conscious or unconscious?

Stable or unstable?

PRIMARY ASSESSMENT

Form a general impression (cont’d).

Information can be used to:

Identify social service needs.

Help direct injury prevention education.

Assess patient needs upon discharge.

Determine the effects of past interventions.

PRIMARY ASSESSMENT

Assessing Level of Consciousness

AVPU GCS

PRIMARY ASSESSMENT

AVPU

• A: Awake and alert

• V: Responds to verbal stimuli

• P: Responds to painful stimuli

• Fingernail pressure

• Pressure to the supraorbital foramen

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PRIMARY ASSESSMENT

AVPU


(cont’d)

• Decorticate posturing (abnormal flexion)

• Decerebrate posturing (abnormal extension)

• U: Unresponsive

PRIMARY ASSESSMENT

Glasgow Coma Scale (GCS)

Scores are added together to define brain function

PRIMARY ASSESSMENT

Glasgow Coma Scale (cont.’d)

Determines:

How to proceed

Care to be given

Where the patient should be transported

PRIMARY ASSESSMENTMethods For Measuring Response To Pain

PRIMARY ASSESSMENT

Airway and breathing

• Listen to the quality of the patient’s voice.

• Nerves responsible for airway control allow for:

• Swallowing

• Controlling the tongue

• Slightly contracted muscles in hypopharynx

PRIMARY ASSESSMENT

Airway and breathing (cont’d)

• If patient is unresponsive, assess the airway.

• Stridor may indicate partial obstruction.

• In the unresponsive, Trismus may indicate:

• A seizure in progress

• Severe head injury

• Cerebral hypoxia

PRIMARY ASSESSMENT


• If you suspect an obstruction:

• Evaluate the airway.

• If there is no response, examine for obstructions.

• Use Magill forceps to remove any objects.

• Be prepared to perform endotracheal intubation.

• Ensure oxygen saturation level of 94%.

PRIMARY ASSESSMENT


• Provide routine hyperventilation only to those patients with both:

• Documented unconsciousness

• Signs of increased intracranial pressure (ICP).

PRIMARY ASSESSMENT

PRIMARY ASSESSMENT

Circulation

Evaluate peripheral and central pulse patterns.

Evaluate skin.

PRIMARY ASSESSMENTCIRCULATION (CONT’D)

Evidence of ICP:

• Cushing reflex

• Decorticate posturing

• Decerebrate posturing

• Biot’s respirations

• Apneustic respirations

• Cheyne-Stokes respirations

• Unresponsive and dilated pupils

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PRIMARY ASSESSMENTCIRCULATION (CONT’D)

Establish vascular access.Establish

Consider drawing blood samples.Consider

Check blood pressure and pulse rate.

• Target systolic pressure: 110 to 120 mm HgCheck

Perform continuous heart monitoring.Perform

PRIMARY ASSESSMENT

Circulation (cont’d)

As the ICP rises: Blood flow to the brain diminishes.

Heart increases contraction force.

Systolic pressure rises.

Ability to send signals is damaged.

Ability to control respiratory and pulse rates is damaged.

PRIMARY ASSESSMENT

Transport decisionConsider how to transport:Complete a rapid secondary assessment.

Complete a secondary assessment and evaluate only the area(s) of patient complaint(s).

HISTORY TAKING

Ask what happened.Ask

Look for signs and symptoms.Look

Evaluate the patient’s speech.Evaluate

HISTORY TAKING

As a paramedic in the field, you may be the only person with the opportunity to obtain crucial information about the time of onset.

SECONDARY ASSESSMENT

Head Neck Chest Abdomen

Pelvis Extremities Back


Note the symmetry of the face.

Ptosis: the dropping sagging, or prolapse of a part of the body



Level of consciousness

•There can be many variations.


AVPU

• A: Awake and alert

• V: Responds to verbal stimuli


• Fingernail pressure

• Pressure to the supraorbital foramen

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AVPU


(cont’d)

• Decorticate posturing (abnormal flexion)

• Decerebrate posturing (abnormal extension)

• U: Unresponsive


Glasgow Coma Scale (GCS)

Scores are added together to define brain function


Glasgow Coma Scale (cont.’d)

Determines:

How to proceed

Care to be given

Where the patient should be transported


Orientation

• Tests mental status.

• Evaluates four areas:

• Person

• Place

• Time

• Event

Confusion may indicate:

• Low blood glucose

• Decreased oxygen

•Overdose

• Decreased blood pressure


Corneal reflex

• Determines intact cough and gag reflexes.

• Tap between the patient’s eyes.

• Patients with reflexes will blink reflexively.

• If the patient does not blink or twitch, assume that the patient does not have an intact cough or gag reflex.


Pupillary Response


Cranial nerve functioning

Abnormal functioning may occur with stroke, trigeminal neuralgia, or myasthenia gravis.



• Listen to the quality of the patient’s speech

• Assess the patient’s ability to recognize objects.

• Ask questions to which you and the patient know the answer,

Speech

Hemiparesis and hemiplegia

Hemiparesis: weakness of one side of the body

Hemiplegia: paralysis of one side of the body

SECONDARY ASSESSMENTBODY MOVEMENT

SECONDARY ASSESSMENTBODY MOVEMENT

Hemiparesis and

hemiplegia Examine the function of

the cerebellum.

• Have patient close eyes and hold out arms.

• If stroke, one arm may drift away from the other.

© Jones & Bartlett Learning. Courtesy of MIEMSS.


• Gait: walking patterns

• Assess by asking patient to walk several steps.

• Posture may become rigid.

Gait and

posture


Alterations in smooth motion

• Rigidity: stiffness of motion

• Tremors: fine, oscillating movement

• Rest tremor: occurs when at rest and not moving

• Intention tremor: occurs when asked to grab object

• Postural tremor: occurs when a body part is required to maintain a particular position


Alterations in smooth motion (cont’d)

• Seizure: larger, less focused movement

• Tonic activity: rigid, contracted body posture

• Clonic activity: rhythmic contraction and relaxation of muscle groups


Sensation

• Paresthesia: sensation of numbness or tingling

• Anesthesia: no feeling within a body part


Blood glucose level

•Normal reading is 60 to 120 mg/dL.

•Below 10 mg/dL is usually fatal.


Vital signs, Document

• Pulse rate, rhythm, and quality

• Respiratory rate, rhythm, and quality

• Blood pressure

• Skin temperature, color, and condition

• Pupil size and reactivity


Vital signs (cont’d)

• Ensure maintenance of a systolic blood pressure of at least 110 to 120 mm Hg.

• Ensure adequate respiratory rate and pattern.

• Ensure effective pulse rate and rhythm.

• If hypothermia or hyperthermia is suspected, use a thermometer to establish temperature.

STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT

Remember, the brain needs oxygen, glucose, and normal temperature to function.

Ensure scene safety and take standard precautions.

Assess airway and breathing.

Assess circulation.


Administration of dextrose 50%

• Dose: 25 g or one full syringe

• Effects begin in 30 seconds to 2 minutes.

• If there is no effect, administer a second dose.

• Can substitute dextrose 25% (two syringes)

One guideline to consider is if the blood glucose level is below 60 mg/dL, then the patient needs glucose.


If you cannot obtain IV access, then administer 0.5 to 1 mg of glucagon subcutaneously or intramuscularly.


If the patient is unresponsive or has decreased LOC and no blood glucose monitor is available,

• Administer 12.5 g (1/2 syringe) of dextrose 50%.

• Reassess.

• Proceed with additional dextrose cautiously.


If the blood glucose level is high, then be aware that

• No safe way to decrease blood glucose in the prehospital setting currently exists.

• Patients with hyperglycemia are often dehydrated and may need volume support.


Airway management

• Provide oxygen, ventilation, and protection.

• Ensure that pulse oximeter reading is 95% or better.

• Provide oxygen and ventilatory assistance as needed.


If trismus is noted:

• If ventilation is poor and patient is breathing on his/her own, attempt a nasotracheal airway.

• If unsuccessful, consider a paralytic agent.

• If paralytics are unavailable, transtracheal airway management is the only option.


Administration of naloxone

• Used for unresponsive/unknown patients or those with suspected narcotic overdose

• Initial dose is 0.4 to 2 mg IVP.

• intranasal (IN) device provides a safe, noninvasive, rapid-acting method of naloxone delivery.

• Can result in rapid change in LOC


Rectal administration of diazepam

• Dose is 0.2 mg/kg.

• Take standard precautions.

• Draw up dose, then remove and dispose of needle.


Communication and documentation

• Notify the receiving facility of:

• Time the patient was last seen healthy

• Findings of neurologic examination

• Anticipated time of arrival at the hospital


• Time of the onset

• Findings from stroke scale and GCS score

• Airway management and interventions performed

• Any change in patient during transport

• Reason for choice of hospital

Document


For patients who have had a seizure, document:

• Description of seizure activity

• Bystanders’ comments

• Onset and duration

• Evidence of trauma

• Interventions performed

• History of seizures


When documenting interventions include:

• Time of each intervention

•How the patient responded

•What the findings showed


Interventions for Increased Intracranial Pressure

The target is a systolic blood pressure of 110 mm

Hg to 120 mm Hg.

COMMON NEUROLOGIC EMERGENCIES

Most diseases or conditions are caused by more than one factor.

• Development of embryo/fetus

• Effectiveness of body’s defense and repair functions

• Exposure to pathogen, toxin, or other damaging factor

STROKE

Blood supply to areas of the brain is interrupted, causing ischemia

Goal of treatment: early recognition and rapid, appropriate intervention

PATHOPHYSIOLOGY OF STROKE

Neurologic conditions can have a vascular origin.Typically result of emboli or aneurysms


Aneurysm development process


• A blood vessel becomes blocked, causing tissue beyond it to become ischemic.

• The severity is dictated by:

• Artery involved

• Portion of the brain being denied oxygen

Ischemic stroke


• Tend to get worse over time

• Bleeding causes increased ICP and brainstem herniation.

• Primary symptom: “worst

headache of my life”

Hemorrhagic stroke


High ICP

Cerebral perfusion

pressure (CPP) begins to fall.

The brain may become ischemic

CPP = MAP – ICP



When ICP climbs and remains high

Herniation may occur.

• Shift or displacement of intracranial contents

• Brainstem will eventually become compressed.

• Patient will lose control of his/her functions.

ASSESSMENT OF STROKE

Language effects

Slurred speech

Aphasia

Movement effects

Hemiparesis

Hemiplegia

Arm drifting

Facial droop

Tongue deviation

Swallowing difficulties

Ptosis

Ataxia

ASSESSMENT OF STROKE

Sensory effects

Headache (hemorrhagic)

Sudden blindness

Sudden unilateral paresthesia

Cognitive effects

Decreased LOC

Difficulty thinking

Seizures

Coma

Cardiac effects

Hypertension

MANAGEMENT OF STROKE

Administer fluids as needed.

Elevate the patient’s head 30°.

Ensure airway is clear.

Watch for seizures.

Monitor blood pressure closely.


High oxygen level constricts arteries.

Lower level of carbon dioxide lowers ICP.


EMS providers need to be involved in educating the community about strokes.

All levels should recognize stroke.

• Use a standard stroke assessment tool.



Transport decisions

Transport to stroke centers.

If you suspect hemorrhagic stroke, consider a facility that can perform neurosurgery.

Call ahead to ensure rapid evaluation.

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TRANSIENT ISCHEMIC ATTACKS

Pathophysiology

• Episodes of cerebral ischemia without permanent damage

• Presentations will resolve within 24 hours.

•May be a sign of a vascular problem


Many TIAs resolve completely within 1 hour—which can mean you are dispatched for stroke, but arrive to find a patient who appears perfectly normal.1

About one-third of patients with TIAs will have an acute stroke sometime in the future


Assessment

Same as assessment for stroke

Management

Follow the stroke management guidelines.

Encourage the patient to be transported and to talk with his/her physician.

COMA

COMA

• History of present illness is vital to determine the underlying cause

• Determine when the patient was last seen normal.

• Evaluate the speed of onset.

Pathophysiology

(cont’d)

COMA

Assessment

Cognitive effects

Decreasing LOC

Confusion

Hallucinations

Psychosis

Difficulty thinking

Sleepiness

Speech effects

Movement effects

CNS effects

Total unresponsiveness

COMA

Management

Support vital functions.

Gather information about the cause.

Administer naloxone if you suspect narcotic overdose.

Patients may need:

Urine and blood analysis

Radiography

Computed tomography

Magnetic resonance imaging

SEIZURES

Pathophysiology

• Sudden erratic firing of neurons

• Signs and symptoms include:

• Muscle spasms

• Increased secretions

• Cyanosis

SEIZURES

Pathophysiology (cont’d)

• If a seizure continues for a long time:

• Cerebral glucose and oxygen supplies can be depleted.

• There can be serious, long-term effects, including death.

SEIZURES

• Medication compliance

• Fever

• Low blood glucose level in diabetics

Try to determine the cause

of the seizure.

SEIZURES

Assessment of generalized seizures

Tonic/clonic steps:

Aura

Loss of consciousness

Tonic phase

Hypertonic phase

Clonic phase

Postseizure

Postictal

SEIZURES

Assessment of generalized seizures (cont’d)

Absence seizures (petit mal seizures)

Typical patient: child

Patient stops and freezes mid-action.

Usually no longer than several seconds

SEIZURES

Assessment of generalized seizures

Pseudoseizures

Cause is of psychiatric origin

Triggered by emotional event, stress, lights, or pain

Motion is relatively organized.

SEIZURES

Assessment of partial seizures

Only a limited part of the brain is involved.

Simple partial seizures involve either:

Movement of one part of the body (frontal lobe)

Sensations in one part of the body (parietal lobe)

SEIZURES MANAGEMENT

Remain calm.Determine

whether trauma is a concern.

Do not restrain the patient.

Prevent the patient from

becoming injured.

Do not place anything in the

patient’s mouth.

SEIZURES MANAGEMENT

Correct hypoglycemia as

needed.

Ventilatory assistance may be necessary.

Provide emotional

support.

All patients should be

transported.

STATUS EPILEPTICUS

• Seizure that lasts longer than 4 to 5 minutes or consecutive seizures

• May result in neurons being damaged or killed

• Goal: stop seizure and ensure adequate ABCs.

Pathophysiology

STATUS EPILEPTICUS

Assessment

Same as for a seizure

Management

Administer a benzodiazepine.

Be prepared to control airway and ventilation.

Paralytics may be needed.

SYNCOPE

Pathophysiology

Sudden and temporary loss of consciousness with loss of postural tone

A short interruption in blood flow causes loss of consciousness.

SYNCOPE

Assessment

Patient is often in a standing position.

Vasovagal syncope typical in younger adults

Cardiac dysrhythmia is a typical cause in older adults.

SYNCOPE

Assessment (cont’d)

Prodromal signs and symptoms may include:

Dizziness

Chest pain

Loss of vision

Incontinence is possible.

SYNCOPE

Management

Determine if trauma has occurred.

Focus on blood pressure and cardiac causes.

Evaluate blood glucose and oxygen saturation.

Obtain orthostatic vital signs.

Provide emotional support and transport.

HEADACHE

Pathophysiology and assessment of muscle tension headaches

Stress causes residual muscle contractions.

Pain is generally felt on both sides of the head.

Usually a dull ache or a squeezing pain

HEADACHE

Pathophysiology and assessment of migraine headaches

Caused by changes in the size of blood vessels at the base of the brain

Patient may report an aura.

Pain is generally unilateral and focused.

HEADACHE

Pathophysiology and assessment of cluster headaches

Begins as minor pain around one eye

Intensifies and spreads to one side of the face.

Occur in groups and last 30–45 minutes each

HEADACHE

Pathophysiology and assessment of sinus headaches

Inflammation/infection within sinus cavities

Pain is located in superior portions of the face.

May be accompanied by postnasal drip, sore throat, and nasal discharge

HEADACHE

Management

Treat for stroke if other signs are present.

Ask what medications patient has taken.

HEADACHE

Management (cont’d)

Medication for pain management:

Ketorolac tromethamine

Meperidine

Morphine

For nausea and vomiting, consider:

Promethazine

Ondansetron

DEMENTIA

Pathophysiology

Chronic deterioration of:

Memory

Personality

Language skills

Perception, reasoning, or judgment

Changes occur over weeks to years.

DEMENTIA


Causes vary.

Wernicke encephalopathy is caused by vitamin B1 deficiency

Alzheimer’s disease is a progressive condition in which neurons die.

DEMENTIA

Assessment

Obvious that it is not simple memory loss

Patients may become aggressive or violent.

Confusion is the hallmark sign.

DEMENTIA

DEMENTIA

Management

Ensure that no reversible cause is present.

Check:

Blood glucose level

Oxygen level

Blood chemistry

DEMENTIA


Wernicke encephalopathy

Administer thiamine before glucose is given.

Perform ECG monitoring.

Obtain blood chemistries.

NEOPLASMS

Pathophysiology

Growths within the body that are caused by errors that occur during cellular reproduction

Mitosis: cellular reproduction

A parent cell divides into two daughter cells.

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NEOPLASMS


Daughter cells are copies of the parent cell.

Ensures continued functioning of vital structures

If a severe error occurs, the cell will have too much damaged DNA to survive.

If a subtle error occurs, the cell may survive.

NEOPLASMSPathophysiology (cont’d)

Benign neoplasms

Not cancerous

Malignant neoplasms

Take over blood supplies.

Move to other sites.

Primary neoplasms

Cancers that arise within the nervous system

Metastatic neoplasms

Cancers that spread to the nervous system

NEOPLASMSAssessment

Signs and symptoms of brain tumors:

Headache

Vomiting

Seizures

Stroke-like symptoms

Signs and symptoms of spinal tumors:

Back pain

Weakness

Loss of limb sensation

Incontinence

NEOPLASMS

Management

Watch for status epilepticus.

Administer diazepam if needed.

Protect limbs from injury.

MULTIPLE SCLEROSIS

Pathophysiology

Autoimmune condition in which the body attacks the myelin of the brain and spinal cord

Results in demyelination

The body begins to attack its own cells.

MULTIPLE SCLEROSIS

Assessment

Follows a pattern of attacks and remissions

Common complaints of initial attack include:

Double vision

Blurred vision

Nystagmus

MULTIPLE SCLEROSIS


Other signs may include:

Muscle weakness

Speech disturbances

Vertigo

Euphoria

Electrical sensations

MULTIPLE SCLEROSIS

Management

Prehospital management is supportive.

Be prepared for trauma related to a fall.

In-hospital treatment is aimed at controlling the symptoms.

GUILLAIN-BARRÉ SYNDROME

Pathophysiology

Disease in which the immune system attacks portions of the nervous system

May report previous respiratory or GI infection

Some patients recover completely; others require assistance for the rest of their lives.


Assessment

Begins as weakness in the legs

Moves up the legs and affects the thorax and arms.

Can lead to paralysis

Patients are prone to severe swings in pulse rate and blood pressure.


Management

Assess ability to protect the airway.

Monitor closely with ECG.

Repeat vital signs.

Obtain continuous end tidal CO2 readings.

Be prepared to administer IV fluids.

Provide comfort.

AMYOTROPHIC LATERAL SCLEROSIS

Strikes the voluntary motor neurons

Cause is unclear

Most common in middle-aged men


Assessment

Initially subtle and progresses without notice

Signs and symptoms include:

Fatigue

General weakness of muscle groups

Difficulty doing routine activities


Management

Monitor the airway.

Transportation may become complicated.

In-hospital care includes:

Physical therapy

Medication to mitigate certain symptoms

PARKINSON’S DISEASE

Pathophysiology

Neurologic condition in which past injuries to the brain can have an influence

The substantia nigra is damaged.


Assessment

Onset is gradual (months to years)

Classic presentation involves:

Tremor

Postural instability

Rigidity

Bradykinesia


Management


Treat any injuries.

In-hospital treatment includes levodopa.

CRANIAL NERVE DISORDERS

Pathophysiology

May mimic other conditions


Assessment

Test for vertigo.

Have patient lie supine.

Move the head rapidly from side to side.

Look at patient’s eyes.

If patient has vertigo, nystagmus will be seen.


Management

For nausea and vomiting, patient may need:

Promethazine

Ondansetron

DYSTONIAPathophysiology

Severe, muscle spasms that cause bizarre contortions, repetitive motions, or postures

Occur for unknown reason

© Dr. P. Marazzi/Photo Researchers, Inc.

DYSTONIA

Assessment

Spasms are involuntary and often painful

Management

Focus on ruling out other problems.

Pain management may be appropriate.

Be calm and reassuring.

CNS INFECTIONS/INFLAMMATION

Pathophysiology

Encephalitis: inflammation of the brain

Meningitis: inflammation of the meninges

Damage is caused by:

Body’s reaction to the infection, or

Activities of the attacking organisms



If temperature becomes too high, a person may:

Hallucinate

Become delusional

Lose consciousness

Have a febrile seizure



Proteins that damage cells

Endotoxins: released by gram-negative bacteria

Exotoxins: secreted by some bacteria or fungi

Virus attacks the axons.

CNS INFECTIONS/INFLAMMATIONAssessment

Both illnesses begin with flulike symptoms.

Meningitis may elicit:

Kernig’s sign

Brudzinski’s sign

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Management

If meningitis is suspected:

Place a mask over the patient’s mouth.

Wear a mask if the patient is coughing.

Be prepared for seizures.



Paramedic may need antibiotic treatment.

Hospital treatment includes:

Decreasing swelling in the brain and spinal cord

Fighting the infection

Supporting the patient’s vital signs

ABSCESSES

Pathophysiology

Caused by an infectious agent within the brain or spinal cord

Often preceded by an infection of the sinuses, throat, gums, or ear

ABSCESSES

Assessment

Signs and symptoms may include:

Low- or high-grade fever

Generalized or focal seizures

Nausea and vomiting

Focal motor or sensory impairments

ABSCESSES

Management

Pay attention for increased ICP.

Take seizure precautions.

Evaluate temperature.

POLIOMYELITIS AND POSTPOLIO SYNDROME

Pathophysiology

Viral infection transmitted by fecal-oral route

Most patients do not become ill.

Assessment

Severe cases:

Sore throat

Nausea, vomiting, diarrhea

Stiff neck

Muscle weakness/ paralysis


Management

In-hospital care is directed at:

Hydration

Ventilation

Calorie support



Prehospital treatment: managing the airway

In-hospital treatment for postpolio includes:

Physical therapy

Experimental medications

PERIPHERAL NEUROPATHY

Pathophysiology

Nerves leaving the spinal cord are damaged.

Causes may include:

Trauma

Toxins

Autoimmune attacks


Assessment

Signs and symptoms may include:

Sensory or motor impairment

Numbness

Pain

Muscle weakness


Management

Supportive in the prehospital setting

In-hospital management includes:

Pain medication

HYDROCEPHALUS

Pathophysiology

Result of an error in the manufacture, movement, or absorption of cerebrospinal fluid

Two main types:

Normal pressure

Increased pressure

HYDROCEPHALUSAssessment (cont’d)

Infant may have:

Increased head circumference

Sun-setting eyes

Tense or bulging fontanelles

Seizures

© M. Ansary/Custom Medical Stock Photo

HYDROCEPHALUS


Older children and adults may have:

Headache

Projectile vomiting

Poor coordination

Memory and personality impairments

HYDROCEPHALUS

Management

A shunt is placed in most patients.

Complications of shunts include:

Inappropriate drainage of CSF

Infection at the site

Length of the tube may become too short.

HYDROCEPHALUS


Be prepared for seizures and increased ICP.

Use of feeding tubes and ventilators is common.

Do not manipulate the VP shunt.

SPINA BIFIDA

Pathophysiology

Neural tube fails to close fully as embryo develops

Part of the nervous system remains outside the body.

SPINA BIFIDA

© Jones & Bartlett Learning

SPINA BIFIDA


If an infection or chemical agent gains access, areas of the brain can be damaged.

A decrease in oxygen can damage the brain.

SPINA BIFIDA

Assessment

Range of complications

None to complete loss of motor and sensory functions

Hydrocephalus is common in children.

SPINA BIFIDA

Management

The patient may be in need of multiple types of medical technology.

In-hospital management is supportive.

Multivitamins are standard during pregnancy.

CEREBRAL PALSY

Pathophysiology

A developmental condition in which damage is done to the brain

Definite cause is unclear.

Will not get worse over time

CEREBRAL PALSY

Assessment

Presentation begins as an infant.

May involve:

Walk with a scissors-like gait

Slow, uncontrolled writhing movements

Tremor

Coordination difficulties

CEREBRAL PALSY

Management


In-hospital management is symptom based.

SUMMARY

Neurologic problems can be dangerous.

The central nervous system has two major structures: the brain and the spinal cord.

The peripheral nervous system consists of the somatic nervous system and the autonomic nervous system.

Each portion of the brain is responsible for specific functions.

SUMMARY

Nerve cells (neurons) transmit signals along their axons and across synapses by means of chemical neurotransmitters.

A variety of disease processes can cause neurologic dysfunction.

Intracranial pressure is determined by the volume of the intracranial contents.

The primary dangers of increased intracranial pressure are ischemia and brain herniation.

SUMMARY

Investigating the neurologic patient’s chief complaint requires taking a history to

determine the mechanism of injury or nature of illness.

It is critical to determine when the patient was last seen normal because the amount of time elapsed since the onset of symptoms will dictate the treatments available.

SUMMARY

Level of consciousness can be evaluated using:

Glasgow Coma Scale and AVPU

A test of corneal reflex or papillary response

Evaluation of cranial nerve functioning

Assessment of the patient’s orientation and alertness

Assessment of the patient’s speech

Evaluation of the patient’s movement

Testing of the patient’s sensory perceptual abilities

Testing of the blood glucose level

Measurement of vital signs

SUMMARY

Following a set of standard care guidelines can help you address common neurologic problems in a systematic way.

Stroke is a condition in which the blood supply to the brain is interrupted.

Stroke causes sudden-onset changes in neurologic status.

Time is brain.

SUMMARY

Transient ischemic attacks are episodes of cerebral ischemia that resolve within 24 hours, leaving no permanent damage.

A diminished level of consciousness is marked by increasing deficits in cognition and speech and changes in movement and posture.

Seizures are caused by the sudden, erratic firing of neurons.

Seizures have a wide range of causes.

SUMMARY

Seizures are classified as either generalized or partial.

Generalized seizures are divided into tonic/clonic seizures, absence seizures, and pseudoseizure.

Simple partial seizures involve either movement or sensations in one part of the body. Complex partial seizures subtly diminish the level of consciousness.

SUMMARY

Status epilepticus is a seizure that lasts longer than 4 to 5 minutes or consecutive seizures without consciousness returning between seizures.

Syncope is caused by a brief interruption in cerebral blood flow that can be traced to cardiac rhythm disturbances, other cardiac causes, or noncardiac causes.

Headaches can be classified as muscle tension, migraine, cluster, or sinus headaches.

SUMMARY

Dementia is characterized by deterioration of memory, personality, language skills, perception, reasoning, or judgment, with no loss of consciousness.

Tumors of the neurologic system affect the brain and spinal cord.

Demyelinating conditions attack the insulating sheath that surrounds and protects the axon, so that nerve impulses can no longer travel smoothly.

SUMMARY

Multiple sclerosis is an autoimmune condition in which episodic attacks are followed by periods of remission.

Amyotrophic lateral sclerosis (Lou Gehrig’s disease) is a disease that strikes the

voluntary motor neurons.

Parkinson’s disease damages the substantia nigra, the portion of the brain that

produces dopamine, which is needed for muscle contraction.

SUMMARY

Cranial nerve disorders have a range of signs and symptoms.

Dystonias are severe, abnormal muscle spasms that cause bizarre contortions, repetitive motions, or postures.

Encephalitis and meningitis are central nervous system infections that cause inflammation of the brain and meninges, respectively.

Abscesses indicate the presence of an infectious agent within the brain or spinal cord.

SUMMARY

Polio is a viral infection that can cause long-term damage to the brain and brainstem, leading to muscle weakness and paralysis.

Peripheral neuropathy is a group of conditions in which the nerves leaving the spinal cord are damaged by trauma, toxins, tumors, autoimmune attack, and metabolic disorders, or other processes.

SUMMARY

Normal-pressure hydrocephalus is a rare condition that occurs in older adults for unknown reasons.

Cerebral palsy is a developmental condition characterized by damage to the frontal lobe of the brain. Its cause is unclear.

CREDITS

Chapter opener: © Mark C. Ide

Backgrounds: Gold—Jones & Bartlett Learning. Courtesy of MIEMSS; Blue—Courtesy of Rhonda Beck; Green—Courtesy of Rhonda Beck; Purple—Courtesy of Rhonda Beck.

Unless otherwise indicated, all photographs and illustrations are under copyright of Jones & Bartlett Learning, courtesy of Maryland Institute for Emergency Medical Services Systems, or have been provided by the American Academy of Orthopaedic Surgeons.

Documents

Neurologic Emergenciestssicu.weebly.com/uploads/1/7/8/0/17806209/neuro.pdf · 2018-11-08 · •Gloves are a standard approach. •Based on the procedure you are conducting and the