ch29

Chapter 29Neurology : 

Chapter 29Neurology Galveston College EMS 2009

Topics : 

2/58 Topics Anatomy and Physiology Pathophysiology General Assessment Findings Management of Nervous System Emergencies

Anatomy and Physiology : 

3/58 Anatomy and Physiology The Central Nervous System The Neuron Protective Structures The Brain The Spinal Cord

Central Nervous System (1 of 7) : 

4/58 The Neuron Central Nervous System (1 of 7)

Central Nervous System (2 of 7) : 

5/58 Central Nervous System (2 of 7) Protective Structures The Skull

Central Nervous System (3 of 7) : 

6/58 Protective Structures The Spine Central Nervous System (3 of 7)

Central Nervous System (4 of 7) : 

7/58 Central Nervous System (4 of 7) Protective Structures The Meninges

Central Nervous System (5 of 7) : 

8/58 Central Nervous System (5 of 7) The Brain Divisions of the Brain Areas of Specialization

Central Nervous System (6 of 7) : 

9/58 Central Nervous System (6 of 7) The Brain Vascular Supply

Central Nervous System (7 of 7) : 

10/58 Central Nervous System (7 of 7) The Spinal Cord

Anatomy and Physiology : 

11/58 Anatomy and Physiology The Peripheral Nervous System The Autonomic Nervous System The Sympathetic Nervous System “Fight-or-flight” The Parasympathetic Nervous System “Feed-or-breed” or “rest-and-repair”

Peripheral Nerves : 

12/58 Peripheral Nerves 43 pairs of nerves originate from the CNS to form the PNS: 12 pairs of cranial nerves originating from the brain 31 pairs of spinal nerves originating from the spinal cord

Peripheral Nervous System : 

13/58 Peripheral Nervous System

Pathophysiology (1 of 2) : 

14/58 Pathophysiology (1 of 2) Alteration in Cognitive Systems CNS Disorders Structural Lesions Toxic Metabolic States Other Causes Cardiovascular Respiratory Infections Drugs

Pathophysiology (2 of 2) : 

15/58 Pathophysiology (2 of 2) Peripheral Nervous System Disorders Mononeuropathy Polyneuropathy

General Assessment Findings (1 of 5) : 

16/58 General Assessment Findings (1 of 5) Scene Size-up and Initial Assessment AVPU General Appearance Speech Skin and Facial Drooping Mood, Thought, Perception, Judgment, Memory, and Attention

General Assessment Findings (2 of 5) : 

17/58 General Assessment Findings (2 of 5) Focused History and Physical Exam History-Taking Trauma-related Underlying medical problems Environmental clues Physical Exam Face, eyes, nose, and mouth

General Assessment Findings (3 of 5) : 

18/58 Respiratory Patterns General Assessment Findings (3 of 5)

General Assessment Findings (4 of 5) : 

19/58 General Assessment Findings (4 of 5) Nervous System Status Sensorimotor Evaluation Motor System and Cranial Nerve Status

General Assessment Findings (5 of 5) : 

20/58 Nervous System Status Glasgow Coma Scale General Assessment Findings (5 of 5)

Pediatric GCS (1 of 2) : 

21/58 Pediatric GCS (1 of 2) Children <2 Years of Age (Non-Verbal): Eye opening: Spontaneous 4 To speech 3 To pain 2 None 1 Verbal: Coos, babbles 5 Cries irritably 4 Cries to pain 3 Moans to pain 2 None 1

Pediatric GCS (2 of 2) : 

22/58 Pediatric GCS (2 of 2) Children <2 Years of Age (Non-Verbal): Motor Response: Normal movements 6 Withdraws to touch 5 Withdraws to pain 4 Abnormal flexion 3 Abnormal extension 2 None 1 Total: Eye+Verbal+Motor = 15

General Assessment Findings (1 of 2) : 

23/58 General Assessment Findings (1 of 2) Vital Signs Cushing’s Reflex

General Assessment Findings (2 of 2) : 

24/58 General Assessment Findings (2 of 2) Other Assessment Tools End-Tidal CO2 Detector Pulse Oximeter Blood Glucometer Geriatric Considerations in Neurological Assessment Ongoing Assessment

Management of Neurological Emergencies : 

25/58 Management of Neurological Emergencies General Principles Airway and Breathing Circulatory Support Pharmacological Intervention Psychological Support Transport Considerations

Altered Mental Status (1 of 3) : 

26/58 Altered Mental Status (1 of 3) AEIOU-TIPS Assessment Management Initial Assessment IV Access Treatable Causes Hypoglycemia, narcotic overdose, suspected alcoholic

Altered Mental Status (2 of 3) : 

27/58 Altered Mental Status (2 of 3) AEIOU TIPS A = acidosis or alcohol E = epilepsy I = infection O = overdose U = uremia T = trauma I = insulin P = psychosis S = stroke

Altered Mental Status (3 of 3) : 

28/58 Altered Mental Status (3 of 3) Chronic Alcoholism Wernicke’s Syndrome Korsakoff’s Psychosis Increased Intracranial Pressure Hyperventilation Mannitol

Stroke and Intracranial Hemorrhage (1 of 5) : 

29/58 Stroke and Intracranial Hemorrhage (1 of 5) Occlusive Strokes Embolic and Thrombotic Strokes Hemorrhagic Strokes

Stroke and Intracranial Hemorrhage (2 of 5) : 

30/58 Stroke and Intracranial Hemorrhage (2 of 5) Signs Facial Drooping Headache Aphasia/Dysphasia Hemiparesis Hemiplegia Paresthesia Gait Disturbances Incontinence Symptoms Confusion Agitation Dizziness Vision Problems

Stroke and Intracranial Hemorrhage (3 of 5) : 

31/58 Stroke and Intracranial Hemorrhage (3 of 5) 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 HTN, prior stroke, or TIA. Symptoms and their progression.

Stroke and Intracranial Hemorrhage (4 of 5) : 

32/58 Stroke and Intracranial Hemorrhage (4 of 5) Management Scene safety and BSI. 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 (5 of 5) : 

33/58 Stroke and Intracranial Hemorrhage (5 of 5)

Seizures (1 of 7) : 

34/58 Seizures (1 of 7) Generalized Seizures Tonic-Clonic Aura Loss of consciousness Tonic phase Hypertonic phase Clonic phase Postseizure Postictal Absence Pseudoseizures

Seizures (2 of 7) : 

35/58 Seizures (2 of 7) 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 (3 of 7) : 

36/58 Seizures (3 of 7) Assessment Differentiating Between Syncope and Seizure Bystanders frequently confuse syncope and seizure.

Seizures (4 of 7) : 

37/58 Seizures (4 of 7) 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

Seizures (5 of 7) : 

38/58 Seizures (5 of 7) Management Scene safety and BSI. 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 (6 of 7) : 

39/58 Seizures (6 of 7) Management Position the patient. Suction if required. Monitor cardiac rhythm. Treat prolonged seizures. Anticonvulsant medication Provide a quiet atmosphere. Transport.

Seizures (7 of 7) : 

40/58 Seizures (7 of 7) 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.

Syncope (1 of 2) : 

41/58 Syncope (1 of 2) 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.

Syncope (2 of 2) : 

42/58 Syncope (2 of 2) Management Scene safety and BSI. Maintain the airway. Support breathing. Check circulatory status. Monitor mental status. Establish IV access. Determine blood glucose level. Monitor the cardiac rhythm. Reassure the patient and transport.

Headache (1 of 4) : 

43/58 Headache (1 of 4) 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 (2 of 4) : 

44/58 Headache (2 of 4) 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.

Headache (3 of 4) : 

45/58 Headache (3 of 4) Assessment What was the patient doing at the onset of pain? Does anything provoke or relieve the pain? What is the quality of the pain? Does the pain radiate to the neck, arm, back, or jaw? What is the severity of the pain? How long has the headache been present?

Headache (4 of 4) : 

46/58 Headache (4 of 4) Management Scene safety and BSI. Maintain the airway. Position the patient. Establish IV access. Determine blood glucose level. Monitor the cardiac rhythm. Consider medication. Antiemetics or analgesics Reassure the patient and transport.

“Weak and Dizzy” (1 of 2) : 

47/58 “Weak and Dizzy” (1 of 2) Assessment Symptomatic of Many Illnesses Focused Assessment Include a detailed neurological exam. Specific signs and symptoms: Nystagmus Nausea and vomiting Dizziness

“Weak and Dizzy” (2 of 2) : 

48/58 “Weak and Dizzy” (2 of 2) Management Scene safety and BSI. 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 (1 of 2) : 

49/58 Neoplasms (1 of 2) 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 (2 of 2) : 

50/58 Neoplasms (2 of 2) 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 : 

51/58 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 (1 of 3) : 

52/58 Degenerative Neurological Disorders (1 of 3) 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 (2 of 3) : 

53/58 Degenerative Neurological Disorders (2 of 3) Types of Disorders (cont.) Parkinson’s Disease Tremor, rigidity, bradykinesia, postural instability Central Pain Syndrome Bell’s Palsy Amytrophic Lateral Sclerosis Myoclonus Spina Bifida Poliomyelitis

Degenerative Neurological Disorders (3 of 3) : 

54/58 Degenerative Neurological Disorders (3 of 3) 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.

Back Pain and Nontraumatic Spinal Disorders (1 of 2) : 

55/58 Back Pain and Nontraumatic Spinal Disorders (1 of 2) Low Back Pain Causes Disk Injury Vertebral Injury Cysts and Tumors Other Causes

Back Pain and Nontraumatic Spinal Disorders (2 of 2) : 

56/58 Back Pain and Nontraumatic Spinal Disorders (2 of 2) 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.

Summary : 

57/58 Summary Anatomy and Physiology Pathophysiology General Assessment Findings Management of Nervous System Emergencies