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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
STRUCTURE OF THE NERVOUS SYSTEM
Central nervous system
• Thought
• Perception
• Feeling
• Autonomic body functions
Peripheral nervous system
• Communication between the brain and the body
STRUCTURE OF THE NERVOUS SYSTEM
© J
one
s &
Bart
lett L
earn
ing
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
NEURONS AND IMPULSE TRANSMISSION
Synapses: slight gap between each cell
Neurotransmitters: connects synapse to next cell
Relay electrically conducted signals
NEURONS AND IMPULSE TRANSMISSION
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
• P: Responds to painful stimuli
(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
Airway and breathing (cont’d)
• 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
Airway and breathing (cont’d)
• 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
21 October 2018
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
SECONDARY ASSESSMENT
Note the symmetry of the face.
Ptosis: the dropping sagging, or prolapse of a part of the body
SECONDARY ASSESSMENT
SECONDARY ASSESSMENT
Level of consciousness
•There can be many variations.
SECONDARY 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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ME
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MT
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SECONDARY ASSESSMENT
AVPU
• P: Responds to painful stimuli
(cont’d)
• Decorticate posturing (abnormal flexion)
• Decerebrate posturing (abnormal extension)
• U: Unresponsive
SECONDARY ASSESSMENT
Glasgow Coma Scale (GCS)
Scores are added together to define brain function
SECONDARY ASSESSMENT
Glasgow Coma Scale (cont.’d)
Determines:
How to proceed
Care to be given
Where the patient should be transported
SECONDARY ASSESSMENT
Orientation
• Tests mental status.
• Evaluates four areas:
• Person
• Place
• Time
• Event
Confusion may indicate:
• Low blood glucose
• Decreased oxygen
•Overdose
• Decreased blood pressure
SECONDARY ASSESSMENT
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.
SECONDARY ASSESSMENT
Pupillary Response
SECONDARY ASSESSMENT
Cranial nerve functioning
Abnormal functioning may occur with stroke, trigeminal neuralgia, or myasthenia gravis.
SECONDARY ASSESSMENT
SECONDARY ASSESSMENT
• 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.
SECONDARY ASSESSMENT
• Gait: walking patterns
• Assess by asking patient to walk several steps.
• Posture may become rigid.
Gait and
posture
SECONDARY ASSESSMENT
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
SECONDARY ASSESSMENT
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
SECONDARY ASSESSMENT
Sensation
• Paresthesia: sensation of numbness or tingling
• Anesthesia: no feeling within a body part
SECONDARY ASSESSMENT
Blood glucose level
•Normal reading is 60 to 120 mg/dL.
•Below 10 mg/dL is usually fatal.
SECONDARY ASSESSMENT
Vital signs, Document
• Pulse rate, rhythm, and quality
• Respiratory rate, rhythm, and quality
• Blood pressure
• Skin temperature, color, and condition
• Pupil size and reactivity
SECONDARY ASSESSMENT
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.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
If you cannot obtain IV access, then administer 0.5 to 1 mg of glucagon subcutaneously or intramuscularly.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
Airway management
• Provide oxygen, ventilation, and protection.
• Ensure that pulse oximeter reading is 95% or better.
• Provide oxygen and ventilatory assistance as needed.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
Rectal administration of diazepam
• Dose is 0.2 mg/kg.
• Take standard precautions.
• Draw up dose, then remove and dispose of needle.
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
• 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
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
When documenting interventions include:
• Time of each intervention
•How the patient responded
•What the findings showed
STANDARD CARE GUIDELINE FORTHE NEUROLOGIC PATIENT
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
PATHOPHYSIOLOGY OF STROKE
Aneurysm development process
PATHOPHYSIOLOGY OF STROKE
• 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
PATHOPHYSIOLOGY OF STROKE
• Tend to get worse over time
• Bleeding causes increased ICP and brainstem herniation.
• Primary symptom: “worst
headache of my life”
Hemorrhagic stroke
PATHOPHYSIOLOGY OF STROKE
High ICP
Cerebral perfusion
pressure (CPP) begins to fall.
The brain may become ischemic
CPP = MAP – ICP
PATHOPHYSIOLOGY OF STROKE
PATHOPHYSIOLOGY OF STROKE
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.
MANAGEMENT OF STROKE
High oxygen level constricts arteries.
Lower level of carbon dioxide lowers ICP.
MANAGEMENT OF STROKE
EMS providers need to be involved in educating the community about strokes.
All levels should recognize stroke.
• Use a standard stroke assessment tool.
MANAGEMENT OF STROKE
MANAGEMENT OF STROKE
Transport decisions
Transport to stroke centers.
If you suspect hemorrhagic stroke, consider a facility that can perform neurosurgery.
Call ahead to ensure rapid evaluation.
28 october
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
TRANSIENT ISCHEMIC ATTACKS
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
TRANSIENT ISCHEMIC ATTACKS
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
Pathophysiology (cont’d)
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
Management (cont’d)
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.
© J
one
s &
Bart
lett L
earn
ing
NEOPLASMS
Pathophysiology (cont’d)
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
Assessment (cont’d)
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.
GUILLAIN-BARRÉ SYNDROME
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.
GUILLAIN-BARRÉ SYNDROME
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
AMYOTROPHIC LATERAL SCLEROSIS
Assessment
Initially subtle and progresses without notice
Signs and symptoms include:
Fatigue
General weakness of muscle groups
Difficulty doing routine activities
AMYOTROPHIC LATERAL SCLEROSIS
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.
PARKINSON’S DISEASE
Assessment
Onset is gradual (months to years)
Classic presentation involves:
Tremor
Postural instability
Rigidity
Bradykinesia
PARKINSON’S DISEASE
Management
Prehospital management is supportive.
Treat any injuries.
In-hospital treatment includes levodopa.
CRANIAL NERVE DISORDERS
Pathophysiology
May mimic other conditions
CRANIAL NERVE DISORDERS
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.
CRANIAL NERVE DISORDERS
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
CNS INFECTIONS/INFLAMMATION
Pathophysiology (cont’d)
If temperature becomes too high, a person may:
Hallucinate
Become delusional
Lose consciousness
Have a febrile seizure
CNS INFECTIONS/INFLAMMATION
Pathophysiology (cont’d)
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
© J
one
s &
Bart
lett L
earn
ing
© J
one
s &
Bart
lett L
earn
ing
CNS INFECTIONS/INFLAMMATION
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.
CNS INFECTIONS/INFLAMMATION
Management (cont’d)
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
POLIOMYELITIS AND POSTPOLIO SYNDROME
Management
In-hospital care is directed at:
Hydration
Ventilation
Calorie support
POLIOMYELITIS AND POSTPOLIO SYNDROME
Management (cont’d)
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
PERIPHERAL NEUROPATHY
Assessment
Signs and symptoms may include:
Sensory or motor impairment
Numbness
Pain
Muscle weakness
PERIPHERAL NEUROPATHY
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
Assessment (cont’d)
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
Management (cont’d)
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
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SPINA BIFIDA
Pathophysiology (cont’d)
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
Prehospital management is supportive.
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.