NeurologyNeurologyChapter #31Chapter #31
Jason N. CookJason N. CookEmergency Care & RescueEmergency Care & Rescue
Weber State UniversityWeber State University
Pathophysiology of CNS Pathophysiology of CNS EmergenciesEmergencies
Structural ChangesStructural Changes Often due to Trauma but not alwaysOften due to Trauma but not always Circulatory ChangesCirculatory Changes
• Inadequate PerfusionInadequate Perfusion
Alterations of ICPAlterations of ICP• Response to insultResponse to insult
Toxic Metabolic statesToxic Metabolic states Alteration to blood chemistry or introduction of toxinsAlteration to blood chemistry or introduction of toxins
Psychiatric ‘mimicking’Psychiatric ‘mimicking’
Nervous System AnatomyNervous System Anatomy Two partsTwo parts
Central nervous system Central nervous system (CNS)(CNS)
Peripheral nervous system Peripheral nervous system (PNS)(PNS)
CNSCNS BrainBrain Spinal cordSpinal cord
• Both encased in and Both encased in and protected by boneprotected by bone
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Peripheral Nervous SystemPeripheral Nervous System 43 pairs of nerves 43 pairs of nerves
originate from CNS to originate from CNS to form PNSform PNS 12 pairs of cranial nerves12 pairs of cranial nerves
• Originate from brainOriginate from brain 31 pairs of spinal nerves31 pairs of spinal nerves
• Originate from spinal cordOriginate from spinal cord
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Cells of the Nervous SystemCells of the Nervous System Neurons—fundamental units Neurons—fundamental units
Neuroglia—connective tissue cellsNeuroglia—connective tissue cells Protect and hold neurons togetherProtect and hold neurons together
NeuronsNeurons Cell body—single nucleus and nucleolusCell body—single nucleus and nucleolus Dendrites—branching projections Dendrites—branching projections Axon—single, elongated projectionAxon—single, elongated projection
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Cells of the Nervous SystemCells of the Nervous System
Neuron with dendrites,Neuron with dendrites,cell body, axoncell body, axon
Neuron
Cells of the Nervous SystemCells of the Nervous System Dendrites transmit impulses Dendrites transmit impulses toto neuron cell neuron cell
bodiesbodies
Axons transmit impulses Axons transmit impulses away from away from cell cell bodiesbodies Bundles of parallel axons with sheaths are white Bundles of parallel axons with sheaths are white
• White matterWhite matter
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Cells of the Nervous SystemCells of the Nervous System In PNS, bundles of axons and their sheaths In PNS, bundles of axons and their sheaths
are called are called nervesnerves Collections of nerve cells are gray Collections of nerve cells are gray
• Gray matterGray matter
Gray matter is integration site within nervous Gray matter is integration site within nervous systemsystem
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Types of NeuronsTypes of Neurons Classified by impulse transmission direction:Classified by impulse transmission direction:
Sensory neuronsSensory neurons• Afferent neuronsAfferent neurons
Motor neuronsMotor neurons• Efforent neuronsEfforent neurons
InterneuronsInterneurons• Connecting neuronsConnecting neurons
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Impulse TransmissionImpulse Transmission Nervous system transmission similar to Nervous system transmission similar to
electrical impulse conduction in heartelectrical impulse conduction in heart
Unmyelinated axonsUnmyelinated axons
Myelinated axonsMyelinated axons
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Nerve Impulse ConductionNerve Impulse Conduction
Unmyelinated fiberUnmyelinated fiber
Myelinated fiberMyelinated fiber
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SynapseSynapse Membrane-to-membrane contactMembrane-to-membrane contact
Separates axon endings of one neuron (presynaptic Separates axon endings of one neuron (presynaptic neuron) from dendrites of another neuron neuron) from dendrites of another neuron (postsynaptic neuron)(postsynaptic neuron) Presynaptic terminalPresynaptic terminal Synaptic cleftSynaptic cleft Plasma membrane of postsynaptic neuronPlasma membrane of postsynaptic neuron
Presynaptic terminals have synaptic vesicles Presynaptic terminals have synaptic vesicles containing neurotransmitter chemicals containing neurotransmitter chemicals
NeurotransmittersNeurotransmitters
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Components of a Synapse Components of a Synapse
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ReflexesReflexes Receive stimulus and generate responseReceive stimulus and generate response
Unidirectional impulse conductionUnidirectional impulse conduction• Sensory receptorSensory receptor
• Sensory neuronSensory neuron
• InterneuronsInterneurons
• Motor neuronMotor neuron
• Effector organEffector organ
Vary in complexityVary in complexity
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Neural Pathway Involved inNeural Pathway Involved inPatellar (“Knee Jerk” ) ReflexPatellar (“Knee Jerk” ) Reflex
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Blood SupplyBlood Supply Arterial blood supply to brainArterial blood supply to brain
Vertebral arteriesVertebral arteries Internal carotid arteriesInternal carotid arteries
Circle of WillisCircle of Willis Safeguard to ensure blood supply to all parts of Safeguard to ensure blood supply to all parts of
the brain if vertebral or internal carotid arteries are the brain if vertebral or internal carotid arteries are blockedblocked
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Blood SupplyBlood Supply
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VeinsVeins Veins that drain blood from head form venous Veins that drain blood from head form venous
sinusessinuses
Drain into internal jugular veinsDrain into internal jugular veins
Internal jugular veins join subclavian veins on Internal jugular veins join subclavian veins on each side of the bodyeach side of the body
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Venous Sinuses AssociatedVenous Sinuses Associatedwith the Brainwith the Brain
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Ventricles of the BrainVentricles of the Brain Lateral ventricleLateral ventricle
Space in cerebral Space in cerebral hemispheres is filled hemispheres is filled with cerebrospinal fluidwith cerebrospinal fluid
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Divisions of the Adult BrainDivisions of the Adult Brain Brain stemBrain stem
MedullaMedulla PonsPons MidbrainMidbrain
CerebellumCerebellum
DiencephalonDiencephalon HypothalamusHypothalamus ThalamusThalamus
CerebrumCerebrum
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Neurological PathophysiologyNeurological Pathophysiology Cerebral blood flow (CBF) interrupted by:Cerebral blood flow (CBF) interrupted by:
Structural changes or damageStructural changes or damage Circulatory changesCirculatory changes Alterations in intracranial pressure (ICP)Alterations in intracranial pressure (ICP)
Three structures in intracranial space:Three structures in intracranial space: Brain tissueBrain tissue BloodBlood WaterWater
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Intracranial SpaceIntracranial Space Brain tissueBrain tissue
Mostly water, intracellular and extracellularMostly water, intracellular and extracellular
BloodBlood Major arteries in base of brainMajor arteries in base of brain Arterial branches, arterioles, capillaries, Arterial branches, arterioles, capillaries,
venules, veins within brain substance venules, veins within brain substance Cortical veins and dural sinusesCortical veins and dural sinuses
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Intracranial SpaceIntracranial Space Water in:Water in:
Ventricles of brainVentricles of brain Cerebrospinal fluidCerebrospinal fluid Extracellular and intracellular fluidExtracellular and intracellular fluid
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Cerebral Perfusion Pressure (CPP)Cerebral Perfusion Pressure (CPP)
Cerebral blood flow depends on cerebral Cerebral blood flow depends on cerebral perfusion pressureperfusion pressure Pressure gradient across brainPressure gradient across brain
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Cerebral Blood FlowCerebral Blood Flow Cerebral blood flow controls oxygen and Cerebral blood flow controls oxygen and
glucose deliveryglucose delivery Cerebral perfusion pressure (CPP) and cerebral Cerebral perfusion pressure (CPP) and cerebral
vascular bed resistancevascular bed resistance CPP determined by:CPP determined by:
• Mean arterial pressure (MAP): (Diastolic pressure + Mean arterial pressure (MAP): (Diastolic pressure + ⅓⅓ pulse pressure) minus intracranial pressurepulse pressure) minus intracranial pressure
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Cerebral Blood FlowCerebral Blood Flow As ICP approaches MAP:As ICP approaches MAP:
Gradient for flow decreasesGradient for flow decreases Cerebral blood flow restrictedCerebral blood flow restricted
When ICP increases, CPP decreasesWhen ICP increases, CPP decreases As CPP decreases, cerebral vasodilation As CPP decreases, cerebral vasodilation Increases cerebral blood volume (increasing Increases cerebral blood volume (increasing
ICP) and further cerebral vasodilationICP) and further cerebral vasodilation
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ICP ReviewICP Review CBF (Cerebral Blood Flow) is a factor of CPP CBF (Cerebral Blood Flow) is a factor of CPP
(Cerebral Perfusion Pressure) & CVR (Cerebral Perfusion Pressure) & CVR (Cerebral Vascular Resistance)(Cerebral Vascular Resistance) If CPP If CPP , then CBF , then CBF If CVR If CVR , then CBF most likely , then CBF most likely
CPP = MAP - ICPCPP = MAP - ICP MAP = Diastolic + 1/3 PPMAP = Diastolic + 1/3 PP PP = SBP - DBPPP = SBP - DBP
PCOPCO22 has greatest effect on CVR has greatest effect on CVR Sympathomimetics may Sympathomimetics may CVR CVR
ICP ReviewICP Review As PCOAs PCO22 , CVR , CVR
Therefore, if PCOTherefore, if PCO22 , CVR , CVR Then, as CVR Then, as CVR , CBF , CBF
Normal ICP < 15 mm HgNormal ICP < 15 mm Hg As ICP As ICP , CPP , CPP then CBF then CBF Compensation for Compensation for ICP via ICP via MAP MAP
Cushing’s Reflex (Triad)Cushing’s Reflex (Triad) Cushing’s triad with coma indicates possible Cushing’s triad with coma indicates possible
herniationherniation
Is unconsciousness itself an Is unconsciousness itself an immediate life threat?immediate life threat?
Loss of airwayLoss of airway Vomiting, aspirationVomiting, aspiration
YES, IT IS!
Altered Mental StateAltered Mental State
Manage ABC’s Before Investigating Cause!
Goals of Emergency CareGoals of Emergency Care Airway controlAirway control
Stabilization and support of cardiovascular systemStabilization and support of cardiovascular system
Intervention to interrupt ongoing cerebral injuryIntervention to interrupt ongoing cerebral injury
Protection from further harmProtection from further harm
Transport to an appropriate medical facilityTransport to an appropriate medical facility
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Initial AssessmentInitial Assessment Level of consciousnessLevel of consciousness
Ensure patent airwayEnsure patent airway
Immobilize cervical spineImmobilize cervical spine
Airway adjuncts if indicatedAirway adjuncts if indicated Monitor for respiratory arrestMonitor for respiratory arrest
Ventilatory support and supplemental oxygen for any Ventilatory support and supplemental oxygen for any neurological emergencyneurological emergency
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Initial Initial Assessment/ManagementAssessment/Management
AirwayAirway Open, clear, maintainOpen, clear, maintain If trauma or If trauma or ++ history, control C-spine history, control C-spine
BreathingBreathing Presence? Adequacy (rate, tidal volume)?Presence? Adequacy (rate, tidal volume)? High concentration OHigh concentration O22 on on ALLALL patients with altered patients with altered
mental statusmental status Assist ventilations prnAssist ventilations prn
CirculationCirculation Pulses? Adequate Perfusion?Pulses? Adequate Perfusion?
HistoryHistory History of event from patient, family, History of event from patient, family,
bystandersbystanders
If loss of consciousness, ascertain events prior If loss of consciousness, ascertain events prior to unconscious state:to unconscious state: Patient position (sitting, standing, lying down)Patient position (sitting, standing, lying down) Complaints of a headacheComplaints of a headache Seizure activitySeizure activity FallFall
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HistoryHistory When no history is available, assume the When no history is available, assume the
onset of unconsciousness was acute and that onset of unconsciousness was acute and that an intracranial hemorrhage is likelyan intracranial hemorrhage is likely
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Investigate CauseInvestigate Cause DERMDERM
DD = Depth of Coma = Depth of Coma EE = Eyes = Eyes RR = Respiratory Pattern = Respiratory Pattern MM = Motor Function = Motor Function
D = Depth of ComaD = Depth of Coma What does patient respond to?What does patient respond to? How does he respond?How does he respond?
Avoid use of non-specific terms like “stuporous”, “semi-conscious”, “lethargic”,
“obtunded”
D = Depth of ComaD = Depth of Coma
AVPUAVPU Glasgow Scale (later)Glasgow Scale (later)
Describe level of consciousness in terms of
reproducible findings
Neurological EvaluationNeurological Evaluation AVPU and Glasgow Coma ScaleAVPU and Glasgow Coma Scale
Determine baseline neurological statusDetermine baseline neurological status Allow comparisonsAllow comparisons
Report and record patient information with Report and record patient information with specific descriptive termsspecific descriptive terms
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E = EyesE = Eyes PupilsPupils
Size - mid, dilated or constrictedSize - mid, dilated or constricted• measurement - e.g. 4 mmmeasurement - e.g. 4 mm
Shape - round, oval, pontineShape - round, oval, pontine Equality - equal in sizeEquality - equal in size Symmetry - equal in reaction/responseSymmetry - equal in reaction/response Response to lightResponse to light
• Yes or NoYes or No
• How? How?
Pupils at DifferentPupils at DifferentLevels of ConsciousnessLevels of Consciousness
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Extraocular MovementsExtraocular Movements Conjugate gazeConjugate gaze
A deviation of both eyes A deviation of both eyes to either side.to either side.• Irritative focusIrritative focus
• Destructive focusDestructive focus
Dysconjugate gazeDysconjugate gaze Deviation of the eyes to Deviation of the eyes to
opposite sidesopposite sides• Brain Stem injuryBrain Stem injury
R = Respiratory PatternR = Respiratory Pattern
DepthDepth Unusually deep or shallow?Unusually deep or shallow?
PatternPattern Regular or Unusual patternRegular or Unusual pattern
• Can you identify the pattern?Can you identify the pattern?
Respiratory PatternsRespiratory Patterns Normal or abnormalNormal or abnormal
Abnormal respiratory patternsAbnormal respiratory patterns Cheyne-Stokes respirationCheyne-Stokes respiration Central neurogenic hyperventilationCentral neurogenic hyperventilation Ataxic respirationAtaxic respiration Apneustic respirationApneustic respiration Diaphragmatic breathingDiaphragmatic breathing
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Respiratory PatternsRespiratory Patterns
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M = Motor FunctionM = Motor Function Paralysis?Paralysis?
Where?Where? Muscle tone? Muscle tone?
Rigid or FlaccidRigid or Flaccid Movement?Movement?
Where? What is it like?Where? What is it like? Posturing? Posturing?
How?How? Symmetrical Motor Function?Symmetrical Motor Function?
Posturing, Muscle Tone, and ParalysisPosturing, Muscle Tone, and Paralysis
Disturbances of posture result from:Disturbances of posture result from: Flexor spasmsFlexor spasms Extensor spasmsExtensor spasms FlaccidityFlaccidity
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Posturing, Muscle Tone, and ParalysisPosturing, Muscle Tone, and Paralysis
Decorticate rigidityDecorticate rigidity FlexionFlexion Abnormal flexor responses of one or both arms Abnormal flexor responses of one or both arms
with extension of legswith extension of legs Structural impairment of certain cortical regions of Structural impairment of certain cortical regions of
brainbrain
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Posturing, Muscle Tone, and ParalysisPosturing, Muscle Tone, and Paralysis
Decerebrate rigidityDecerebrate rigidity ExtensionExtension Abnormal extensor response of arms and legs Abnormal extensor response of arms and legs Worse prognosis than decorticate rigidityWorse prognosis than decorticate rigidity Impairment of subcortical regions of brainImpairment of subcortical regions of brain
FlaccidityFlaccidity Brain stem or cord dysfunctionBrain stem or cord dysfunction Dismal prognosisDismal prognosis
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PosturingPosturing
Abnormal extension (decerebrate posturing)
Abnormal flexion (decorticate posturing)
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Assessment—Abnormal ReflexesAssessment—Abnormal Reflexes
Positive Babinski's signPositive Babinski's sign Plantar reflexPlantar reflex Dorsiflexion of great toe Dorsiflexion of great toe
with or without fanning of with or without fanning of toestoes
Relaxation of sphincter Relaxation of sphincter tone with evacuation of tone with evacuation of bowels and/or bladderbowels and/or bladder
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Vital SignsVital Signs Assess and record frequentlyAssess and record frequently
May change rapidly May change rapidly Monitor ECG for dysrhythmiasMonitor ECG for dysrhythmias
Cushing’s triad, if increased ICP:Cushing’s triad, if increased ICP: Increase in systolic pressure (widening pulse Increase in systolic pressure (widening pulse
pressure)pressure) Decrease in pulse rateDecrease in pulse rate Irregular respiratory patternIrregular respiratory pattern
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Physical ExamPhysical Exam Vital SignsVital Signs
Shock? Shock? Increased ICP? Increased ICP? Hypoxia/HypercarbiaHypoxia/Hypercarbia
DiagnosticsDiagnostics Dysrhythmias?Dysrhythmias? Blood glucoseBlood glucose Oxygen saturationOxygen saturation
Physical ExamPhysical Exam Detailed (Head-to-Toe) ExamDetailed (Head-to-Toe) Exam
Injuries causing coma?Injuries causing coma? Injuries caused by coma?Injuries caused by coma? Clues to the causeClues to the cause
Probable Causes of AMSProbable Causes of AMS Not enough Not enough OxygenOxygen Not enough Not enough SugarSugar Not enough Not enough blood flowblood flow to deliver oxygen, to deliver oxygen,
sugarsugar Direct brain Direct brain injuryinjury
StructuralStructural MetabolicMetabolic
Differentiating AMS CausesDifferentiating AMS Causes StructuralStructural
Asymmetrical Asymmetrical deficitsdeficits
Unequal pupilsUnequal pupils AfebrileAfebrile History of trauma, History of trauma,
structural structural abnormalityabnormality
Often a rapid Often a rapid onsetonset
MetabolicMetabolic Symmetrical deficitsSymmetrical deficits Equal pupils Equal pupils
(? altered function)(? altered function) ? Fever? Fever History of metabolic History of metabolic
disorder or illnessdisorder or illness Rapid onset less Rapid onset less
likelylikely
ManagementManagement Maintain ABCsMaintain ABCs Attempt to identify causeAttempt to identify cause Mainstays of therapyMainstays of therapy
Oxygenation/VentilationOxygenation/Ventilation IV fluids appropriate for the patientIV fluids appropriate for the patient D50 (if hypoglycemic)D50 (if hypoglycemic) Narcan if possibility of opiate ODNarcan if possibility of opiate OD Flumazenil in known benzo only ODFlumazenil in known benzo only OD
ComaComa A decreased state of consciousness A decreased state of consciousness
from which a patient cannot be arousedfrom which a patient cannot be aroused
MechanismsMechanisms Structural lesionsStructural lesions Toxic Metabolic statesToxic Metabolic states Psychiatric ‘mimicking’Psychiatric ‘mimicking’
Brain injuryBrain injury Recall that Brain injury is often shown by:Recall that Brain injury is often shown by:
Altered Mental StatusAltered Mental Status SeizuresSeizures Localizing signsLocalizing signs
Stroke and Intracranial HemorrhageStroke and Intracranial Hemorrhage
Stroke (“brain attack”)Stroke (“brain attack”)
Sudden interruption in brain blood flow Sudden interruption in brain blood flow
Results in neurological deficitResults in neurological deficit IncidenceIncidence Morbidity/mortalityMorbidity/mortality Risk factorsRisk factors
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Stroke PathophysiologyStroke Pathophysiology Blood supply to brain through Blood supply to brain through
four vesselsfour vessels Carotid arteriesCarotid arteries
• 80% of cerebral blood flow80% of cerebral blood flow Vertebral arteriesVertebral arteries
• Form basilar arteryForm basilar artery• 20% of cerebral blood flow20% of cerebral blood flow
Interconnected at various Interconnected at various levelslevels• Circle of WillisCircle of Willis
Onset and symptoms depend Onset and symptoms depend on area of brain involvedon area of brain involved
Types of StrokeTypes of Stroke Neurological manifestations of Neurological manifestations of
decrease in blood flow to braindecrease in blood flow to brain Ischemic and hemorrhagic Ischemic and hemorrhagic
strokesstrokes Both can be life threateningBoth can be life threatening Ischemic stroke rarely causes death Ischemic stroke rarely causes death
in first hourin first hour Hemorrhagic stroke can be rapidly Hemorrhagic stroke can be rapidly
fatalfatal
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Ischemic StrokeIschemic Stroke 85% of strokes are 85% of strokes are
ischemicischemic Cerebral thrombosis due Cerebral thrombosis due
to:to: Atherosclerotic plaquesAtherosclerotic plaques Extrinsic pressure brain Extrinsic pressure brain
massmass Thrombotic strokeThrombotic stroke
Slower to develop than Slower to develop than cerebral hemorrhagecerebral hemorrhage
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Cerebral EmbolusCerebral Embolus Intracranial vessel occluded by foreign Intracranial vessel occluded by foreign
substance from outside CNS.substance from outside CNS. Signs and symptomsSigns and symptoms
Similar to thrombotic strokeSimilar to thrombotic stroke Usually develop more quicklyUsually develop more quickly Often have identifiable causeOften have identifiable cause
Hemorrhagic StrokeHemorrhagic Stroke IncidenceIncidence
Morbidity/mortalityMorbidity/mortality
CausesCauses Cerebral aneurysmsCerebral aneurysms Arteriovenous (AV) Arteriovenous (AV)
malformationsmalformations HypertensionHypertension
Signs and symptomsSigns and symptoms
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Transient Ischemic AttacksTransient Ischemic Attacks Focal cerebral dysfunction lasting from minutes Focal cerebral dysfunction lasting from minutes
to several hoursto several hours
Return to normal Return to normal <<24 hrs24 hrs
No permanent neurological deficitNo permanent neurological deficit Indication of impending strokeIndication of impending stroke
Signs and symptomsSigns and symptoms
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Differentiating between Ischemic and Differentiating between Ischemic and Hemorrhagic StrokeHemorrhagic Stroke
Ischemic StrokeIschemic Stroke Hemorrhagic StrokeHemorrhagic Stroke
Most commonMost common Least commonLeast common
Atherosclerosis or tumor within Atherosclerosis or tumor within brainbrain
Cerebral aneurysms, AV Cerebral aneurysms, AV malformations, hypertensionmalformations, hypertension
Slow onsetSlow onset Abrupt onsetAbrupt onset
Long history of vessel diseaseLong history of vessel disease Stress or exertionStress or exertion
Valvular heart disease and atrial Valvular heart disease and atrial fibrillationfibrillation
Cocaine and other Cocaine and other sympathomimetic aminessympathomimetic amines
Hx of angina, previous strokesHx of angina, previous strokes May be asymptomatic before May be asymptomatic before rupturerupture
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AssessmentAssessment Emergency care prioritiesEmergency care priorities
Maintain patent airwayMaintain patent airway Provide adequate ventilatory supportProvide adequate ventilatory support OxygenOxygen Thorough historyThorough history
ManagementManagement Time in field must be reducedTime in field must be reduced Establish time of symptom onset (if possible)Establish time of symptom onset (if possible) Supportive measuresSupportive measures
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Cincinnati Prehospital Stroke Cincinnati Prehospital Stroke ScaleScale
A simple version of the National Institutes of Health Stroke A simple version of the National Institutes of Health Stroke ScaleScale
Accurate in identifying patients with strokeAccurate in identifying patients with stroke An abnormal finding in ANY of the three tests strongly suggests An abnormal finding in ANY of the three tests strongly suggests
a stroke. a stroke.
Facial DroopFacial Droop Arm DriftArm Drift Slurred SpeechSlurred Speech
Los Angeles Prehospital Stroke Screen Los Angeles Prehospital Stroke Screen (LAPSS)(LAPSS)
AgeAge HistoryHistory Symptom durationSymptom duration Baseline disabilityBaseline disability
Identifies asymmetry in:Identifies asymmetry in:• Facial smile/grimaceFacial smile/grimace
• GripGrip
• Arm strengthArm strength
Asymmetry in any category indicates a possible strokeAsymmetry in any category indicates a possible stroke
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Prehospital Stroke ManagementPrehospital Stroke Management
Rapid transportRapid transport Determine time of symptom onsetDetermine time of symptom onset Manage airwayManage airway Oxygen if SaO2 <92%Oxygen if SaO2 <92% Monitor vital signs and ECGMonitor vital signs and ECG Initiate IV en routeInitiate IV en route Assess blood glucoseAssess blood glucose Control seizures with benzodiazepinesControl seizures with benzodiazepines
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HeadacheHeadache Categorized by underlying cause:Categorized by underlying cause:
Tension headachesTension headaches MigrainesMigraines Cluster headachesCluster headaches Sinus headachesSinus headaches
Common medical complaintCommon medical complaint
Tension HeadachesTension Headaches Muscle contractions of face, neck, scalpMuscle contractions of face, neck, scalp
CausesCauses
Signs and symptomsSigns and symptoms
ManagementManagement
MigrainesMigraines Severe, incapacitating headachesSevere, incapacitating headaches
Often preceded by visual or GI disturbancesOften preceded by visual or GI disturbances
Intense, throbbing pain on one side of headIntense, throbbing pain on one side of head May spreadMay spread Often nausea and vomitingOften nausea and vomiting
Constriction and dilation of blood vesselsConstriction and dilation of blood vessels Imbalance of serotonin or hormone fluctuationsImbalance of serotonin or hormone fluctuations
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MigrainesMigraines Also triggered by:Also triggered by:
Excessive caffeine useExcessive caffeine use Various foodsVarious foods Changes in altitudeChanges in altitude Extremes of emotionsExtremes of emotions
ManagementManagement
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Cluster HeadachesCluster Headaches Occur in bursts (clusters)Occur in bursts (clusters)
Often several hours after asleepOften several hours after asleep
PainPain SevereSevere Usually around one eyeUsually around one eye Often nasal congestion and tearingOften nasal congestion and tearing Often lasts 30 min to 2 hrs, and recurs a day or so laterOften lasts 30 min to 2 hrs, and recurs a day or so later May occur every day for months before long periods of May occur every day for months before long periods of
remissionremission
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Cluster HeadachesCluster Headaches Histamine headachesHistamine headaches
Release of histamine from tissuesRelease of histamine from tissues SymptomsSymptoms
• Dilated carotid arteriesDilated carotid arteries
• Fluid accumulation under eyesFluid accumulation under eyes
• Tearing Tearing
• RhinorrheaRhinorrhea
ManagementManagement
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Sinus HeadachesSinus Headaches Pain in forehead, nasal area, and eyesPain in forehead, nasal area, and eyes
Feeling of pressure behind faceFeeling of pressure behind face
Inflammation or infection of membranes lining Inflammation or infection of membranes lining sinus cavities or allergiessinus cavities or allergies
ManagementManagement
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Brain NeoplasmBrain Neoplasm Mass in cranial cavityMass in cranial cavity
Malignant or benignMalignant or benign
Risk factorsRisk factors
Signs and symptomsSigns and symptoms
ManagementManagement
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Brain AbscessBrain Abscess Accumulation of purulent material (pus) Accumulation of purulent material (pus)
surrounded by a capsule within brainsurrounded by a capsule within brain
CausesCauses
Clinical manifestationsClinical manifestations
Management Management
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Muscular DystrophyMuscular Dystrophy Inherited muscle disorderInherited muscle disorder
Unknown causeUnknown cause
Slow, progressive degeneration of muscle Slow, progressive degeneration of muscle
Different forms classified by:Different forms classified by: Age symptoms appearAge symptoms appear Rate of disease progressionRate of disease progression How inheritedHow inherited
Duchenne muscular dystrophyDuchenne muscular dystrophy Most common typeMost common type
Muscular Muscular DystrophyDystrophy
Multiple Sclerosis (MS)Multiple Sclerosis (MS) Progressive CNS disease Progressive CNS disease
Scattered patches of myelin in brain and Scattered patches of myelin in brain and spinal cord are destroyedspinal cord are destroyed CauseCause IncidenceIncidence Morbidity/mortalityMorbidity/mortality Clinical manifestationsClinical manifestations ManagementManagement
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DystoniaDystonia Local or diffuse alterations in muscle tone Local or diffuse alterations in muscle tone
Usually abnormal muscle rigidityUsually abnormal muscle rigidity
CausesCauses Painful muscle spasmsPainful muscle spasms Unusually fixed posturesUnusually fixed postures Strange movement patternsStrange movement patterns
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DystoniaDystonia Localized dystoniaLocalized dystonia
Torticollis (painful neck spasm)Torticollis (painful neck spasm) Scoliosis (abnormal curvature of the spine)Scoliosis (abnormal curvature of the spine)
Generalized dystoniaGeneralized dystonia Parkinson diseaseParkinson disease StrokeStroke
Also feature of schizophrenia or side effect of Also feature of schizophrenia or side effect of antipsychotic drugsantipsychotic drugs
ManagementManagement
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Parkinson DiseaseParkinson Disease Degeneration or damage to nerve cells within basal Degeneration or damage to nerve cells within basal
ganglia in brainganglia in brain
Leading neurologic disability in persons over 60 yoLeading neurologic disability in persons over 60 yo
Characterized by :Characterized by : Muscle rigidityMuscle rigidity Tremors (start on one side)Tremors (start on one side) WeaknessWeakness Shuffling gaitShuffling gait May lead to dementiaMay lead to dementia
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Central Pain SyndromeCentral Pain Syndrome Infection or disease of trigeminal nerve (cranial nerve Infection or disease of trigeminal nerve (cranial nerve
V)V) Tic douloureux (trigeminal neuralgia)Tic douloureux (trigeminal neuralgia)
• Common form Common form • Excruciating painExcruciating pain
Affects one side of faceAffects one side of face
Brief attacks of intense painBrief attacks of intense pain
May be associated with MS in persons under 50 yoMay be associated with MS in persons under 50 yo
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Bell’s Palsy (Facial Palsy) Bell’s Palsy (Facial Palsy) Paralysis of facial musclesParalysis of facial muscles
Inflammation of seventh cranial nerveInflammation of seventh cranial nerve Usually one sided and temporaryUsually one sided and temporary Often develops suddenlyOften develops suddenly
Affects 1 in 60 or 70 peopleAffects 1 in 60 or 70 people
Often spontaneous recoveryOften spontaneous recovery
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Bell’s Palsy Bell’s Palsy
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Amyotrophic Lateral Sclerosis (ALS)Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s diseaseLou Gehrig’s disease
Rare disorders (motor neuron disease)Rare disorders (motor neuron disease)
Nerves that control muscular activity degenerate within Nerves that control muscular activity degenerate within brain and spinal cordbrain and spinal cord
Often begins with weakness in the arms and handsOften begins with weakness in the arms and hands
Paralysis progresses to include respiratory musclesParalysis progresses to include respiratory muscles
Death often within 2-4 years of diagnosisDeath often within 2-4 years of diagnosis
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Peripheral NeuropathyPeripheral Neuropathy Diseases and disorders affecting peripheral nervous Diseases and disorders affecting peripheral nervous
system, including:system, including: Spinal nerve rootsSpinal nerve roots Cranial nervesCranial nerves Peripheral nervesPeripheral nerves
Damage or irritation of axons or myelin sheathsDamage or irritation of axons or myelin sheaths
Affect different areas of bodyAffect different areas of body
Many medical causesMany medical causes
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MyoclonusMyoclonus Rapid and uncontrollable muscular Rapid and uncontrollable muscular
contractions (jerking) or spasms of muscle(s)contractions (jerking) or spasms of muscle(s) Occur at rest or with movementOccur at rest or with movement
Associated with:Associated with: Disease of nerves and musclesDisease of nerves and muscles Brain disorder (e.g., encephalitis)Brain disorder (e.g., encephalitis) Seizure disorderSeizure disorder
May occur in healthy personsMay occur in healthy persons
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Spina BifidaSpina Bifida Congenital defectCongenital defect
One or more vertebrae fail to develop completelyOne or more vertebrae fail to develop completely Leaves portion of spinal cord exposedLeaves portion of spinal cord exposed
Most common in lower backMost common in lower back
Incidence Incidence Morbidity/mortalityMorbidity/mortality
Cause is unknownCause is unknown
Types of Spina BifidaTypes of Spina Bifida Severity depends on how much nerve tissue Severity depends on how much nerve tissue
is exposed after neural tube closureis exposed after neural tube closure Spina bifida occultSpina bifida occult MeningoceleMeningocele MyeloceleMyelocele EncephaloceleEncephalocele
Polio (Poliomyelitis)Polio (Poliomyelitis) Caused by Caused by poliovirus hominispoliovirus hominis
Incidence declined in 1950s after vaccineIncidence declined in 1950s after vaccine
Risk if unvaccinated and traveling abroadRisk if unvaccinated and traveling abroad
Febrile illness with or without paralysisFebrile illness with or without paralysis
Can cause breathing difficultyCan cause breathing difficulty
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