NeurologyChapter 3

Anatomy and Physiology• Neuron:

– Dendrites– Cell body (soma)– Axon

The Nervous System• Peripheral

– Somatic– Automatic

• Sympathetic• Parasympathetic

• Central– Brain– Spinal Cord

Depolarization• At rest, neuron is positively charged on

outside and negatively charged inside.

Neurotransmitters• Norepinephrine• Seratonin• Acetylcholine• Dopamine

Neurotransmitters• Acetylcholine

– Somatic (voluntary)– Parasympathetic

• Norepinephrine– Sympathetic

Meninges

Brain Anatomy

Brain Anatomy• Cerebrum-All sensory and motor..

Intelligence, memory, learning, analysis• Diencephalon (interbrain)- contains

thalmus and hypothalmus

More Brain Anatomy• Hindbrain

– Cerebellum: Fine motor movement, equilibrium, muscle tone

– Brainstem• Mesencephalon (eye movement)• Pons – connection between brain and

spinal cord• Medulla Oblongata- Division between

brain and spinal cord– Respiration, cardiac activity, vasomotor

activity

Normal Brain

Central Nervous System

• The Brain– Vascular Supply

• Carotid system• Vertebro-basilar• Circle of Willis

Cranial Nerves

Central Nervous System• The Spinal Cord

– Responsible for • Conducting impulses to

and from the peripheral nervous system

• Reflexes • 31 pair of nerves exit

spinal cord

Central Nervous System• The Spinal Cord

– Dorsal Roots• Afferent fibers (To)

– Ventral Roots• Efferent fibers (Away)

Dermatomes

The Autonomic Nervous System

• The Sympathetic Nervous System– “Fight-or-flight”– Neurotransmitters epinephrine and

norepinephrine • The Parasympathetic Nervous System

– “Feed-or-breed” or “rest-and-repair”– Mediated by the neurotransmitter

acetylcholine

Altered Mental Status• Structural Lesions

– Tumors– Bleeds– Trauma

• Toxic Metabolic States– Diabetic Ketoacidosis– Thiamine insufficiency

• Respiratory Patterns– Any of five abnormal

respiratory patterns may be observed

General Assessment Findings

• http://www.youtube.com/watch?v=euUHyL0oLjI&feature=results_main&playnext=1&list=PLE19E9135F6DE2FF5

PaCO2

Posturing

Dolls Eyes

Cushing’s Triad• Increased Blood Pressure• Decreased Pulse• Irregular Respirations

General Assessment Findings• Vital Signs

– Cushing’s Reflex

AEIOU TIPS • A = acidosis or alcohol• E = epilepsy• I = infection• O = overdose• U = uremia

• T = trauma• I = insulin• P = psychosis• S = stroke

Why do we give Thiamine?• Needed for conversion of pyruvic

acid to acetyl-coenzyme-A

Chronic Alcoholism• Wernicke’s Syndrome• Korsakoff’s Psychosis

Altered Mental Status• Wernicke-Korsakoff • Thiamine deficient

– Wernicke’s Syndrome– Korsakoff’s Psychosis

Stroke• Occlusive

– Embolitic– Thrombotic

• Hemorrhagic

Stroke and Intracranial Hemorrhage

• General term that describes injury or death of brain tissue – Usually due to interrupted blood flow– “Brain attack”

• Transport considerations– CT– Neurological services– Fibrinolytics available– Warrants rapid recognition and prompt transport

Stroke and Intracranial Hemorrhage

• Occlusive Strokes– Embolic and

Thrombotic Strokes

• Hemorrhagic Strokes

Save the Penumbra

Stroke and Intracranial Hemorrhage

• Signs– Facial Drooping– Headache– Aphasia/Dysphasia– Hemiparesis– Hemiplegia– Paresthesia– Gait Disturbances– Incontinence

• Symptoms– Confusion– Agitation– Dizziness– Vision Problems

Prehospital Stroke Screens

• http://www.activase.com/resource-center/video-library.jsp?tab=0

• http://atlanticneurosurgical.com/services/stroke_treatment.php

Stroke and Intracranial Hemorrhage

• Management– Scene safety and standard precautions– Maintain the airway– Support breathing– Obtain a detailed history– Position the patient– Determine the blood glucose level– Establish IV access– Monitor the cardiac rhythm– Protect paralyzed extremities

Stroke and Intracranial Hemorrhage

• Transient Ischemic Attacks– Indicative of carotid artery disease– Symptoms of neurological deficit:

• Symptoms resolve in less than 24 hours• No long-term effects

– Evaluate through history taking:• History of hypertension, prior stroke, or TIA• Symptoms and their progression

Seizures• Generalized Seizures

– Tonic-Clonic• Aura• Loss of consciousness• Tonic phase• Hypertonic phase• Clonic phase• Postseizure• Postictal

– Absence• Petit-mal• 10- to 30-second loss of consciousness or

awareness • Eye or muscle twitching

Seizures• Generalized Seizures (cont.)

– Pseudoseizures• Hysterical seizures • Stems from psychological disorders• Can often be interrupted with a terse

command

Seizures• Partial Seizures

– Simple Partial Seizures• Involve one body area• Can progress to generalized seizure

– Complex Partial Seizures• Characterized by auras• Typically 1–2 minutes in length• Loss of contact with surroundings

Seizures• Assessment

– Ascertain exactly what the patient may recall or what bystanders witnessed

• Other problems mimic seizure – Differentiating Between Syncope and Seizure

Seizures• Patient History

– History of Seizures– History of Head Trauma– Any Alcohol or Drug Abuse– Recent History of Fever, Headache, or Stiff Neck– History of Heart Disease, Diabetes, or Stroke– Current Medications

• Phenytoin (Dilantin), phenobarbitol, valproic acid (Depakote), or carbamazepine (Tegretol)

– Physical Exam• Signs of head trauma or injury to tongue• Alcohol or drug abuse

• Management– Scene safety and standard precautions– Maintain the airway– Administer high-flow, high-concentration oxygen– Establish IV access– Treat hypoglycemia if present– Do not restrain the patient

• Protect the patient from the environment– Maintain body temperature

Seizures

Seizures• Management (cont.)

– Position the patient– Suction if required– Monitor cardiac

rhythm– Treat prolonged

seizures• Anticonvulsant

medication– Provide a quiet

atmosphere– Transport

Seizures• Status Epilepticus

– Two or More Generalized Seizures• Seizures occur without a return of

consciousness– Management

• Management of airway and breathing is critical

• Establish IV access and cardiac monitoring• Administer 25 g 50% dextrose if hypoglycemia

is present• Administer 5–10 mg diazepam IV• Monitor the airway closely

• http://www.youtube.com/watch?v=MRZY2a2jnuw

• http://www.youtube.com/watch?v=rtjPs_B99Bo• http://www.youtube.com/watch?v=H3iLQi6wt94• http://www.youtube.com/watch?v=wmAiABeP0

8k• http://www.youtube.com/watch?v=ivXW5sjcRic

&feature=related

• http://www.youtube.com/watch?v=BzIs8YeafZM&feature=related

• http://www.youtube.com/watch?v=dKItDS30nvc

Syncope• A sudden, temporary loss of consciousness• Assessment

– Cardiovascular:• Dysrhythmias or mechanical problems

– Noncardiovascular:• Metabolic, neurological, or psychiatric condition

– Idiopathic:• The cause remains unknown even after careful assessment

– Extended unconsciousness is NOT syncope

Headache• Types

– Vascular• Migraines

– Throbbing pain, photosensitivity, nausea, vomiting, and sweats; more frequent in women

– May last for extended periods of time• Cluster

– One-sided with nasal congestion, drooping eyelid, and irritated or watery eye; more frequent in men

– Typically last 1–4 hours

Headache• Types

– Tension– Organic

• Occur due to tumors, infection, or other diseases of the brain, eye, or other body system

• Headaches associated with fever, confusion, nausea, vomiting, or rash can be indicative of an infectious disease

“Weak and Dizzy”• Assessment

– Symptomatic of Many Illnesses– Focused Assessment

• Include a detailed neurological exam• Specific signs and symptoms:

– Nystagmus– Nausea and vomiting– Dizziness

“Weak and Dizzy”• Management

– Scene safety and standard precautions– Maintain airway and administer high-flow,

high-concentration oxygen– Position of comfort– Establish IV access and monitor cardiac rhythm– Determine blood glucose level– Consider medication:

• Antiemetic– Transport and reassure patient

Neoplasms• Tumors

– Benign– Malignant

• Assessment– Signs and Symptoms

• Recurring or severe headaches• Nausea and vomiting• Weakness or paralysis• Lack of coordination or unsteady gait• Dizziness, double vision• Seizures without a prior history of seizures

Neoplasms• Assessment (cont.)

– History• Surgery, chemotherapy, radiation therapy, or holistic therapy• Experimental treatments

• Management– Scene size-up and BSI– Maintain airway and administer high-flow,

high-concentration oxygen– Position of comfort– Establish IV access and monitor cardiac rhythm– Consider medication administration:

• Analgesics, antiseizure meds, anti-inflammatory meds– Transport and reassure patient

Brain Abscess• Abscess

– Collection of Pus• Assessment

– Signs and Symptoms• Lethargy, hemiparesis, nuchal rigidity• Headache, nausea, vomiting, seizures

• Management– Similar to Neoplasm

Degenerative Neurological Disorders

• Types of Disorders– Alzheimer’s Disease

• Most frequent cause of dementia in the elderly• Results in atrophy of the brain due to nerve cell death

in the cerebral cortex– Muscular Dystrophy

• Characterized by progressive muscle weakness– Multiple Sclerosis

• Unpredictable disease resulting from deterioration of the myelin sheath

– Dystonias

Degenerative Neurological Disorders

• Types of Disorders (cont.)– Parkinson’s Disease

• Tremor, rigidity, bradykinesia, postural instability– Central Pain Syndrome– Bell’s Palsy– Amytrophic Lateral Sclerosis– Spina Bifida– Poliomyelitis

Alzheimer’s Disease

Pick’s Disease

Huntington’s Disease

Muscular Dystrophy

Muscular Dystrophy

Multiple Sclerosis

Dystonia

Parkinson’s

Bell’s Palsy

ALS • Amyotrophic Lateral Sclerosis

Spinal Bifida

Polio

Degenerative Neurological Disorders

• Assessment– Obtain history– Exacerbation of chronic illness or new problem?

• Management– Special Considerations

• Mobility, communication, respiratory compromise, and anxiety

– Interventions• Determine blood glucose level• Establish IV access• Monitor cardiac rhythm• Transport and reassure the patient

• Low Back Pain• Causes

– Disk Injury– Vertebral Injury– Cysts and Tumors– Other Causes

Back Pain and Non-Traumatic Spinal Disorders

Disc Issues

Back Pain and Non-Traumatic Spinal Disorders

• Assessment– Evaluate history

• Speed of onset• Risk factors such as vibration or repeated lifting• Determine if pain is related to a life-threatening problem

• Management– Consider c-spine

• Immobilize if in doubt– Consider analgesics

Overuse/Repetitive-Motion Disorders

• Tennis Elbow• Golfer’s Elbow• Tenosynovitis- similar to tendonitis• Bursitis• Myalgias-muscle pain• Carpal Tunnel- median nerve

Osteoarthritis

Osteoporosis

Rheumatoid Arthritis

Ankylosing Spondylitis“bamboo spine”

Lupus

Gout

Cellulitis

Fasciitis

Necrotizing fasciitis

Gangrene

Osteomyelitis

Chronic Pain Syndrome

Fibromyalgia(Central Sensitivity Syndrome)

Osgood-Schlatter Disease

Slipped Capital Femoral Epiphysis

Epidural Hematoma