11. Anatomy & 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”
12. Pathophysiology
Alteration in Cognitive Systems
CNS Disorders
Structural Lesions (Tumor, contusions)
Toxic Metabolic States
Other Causes
Cardiovascular
Respiratory
Infections
Drugs
20. General Assessment
Findings
Other Assessment Tools
• End-Tidal CO2 Detector
• Pulse Oximeter
• Blood Glucometer
Geriatric Considerations in Neurological
Assessment
Ongoing Assessment
21. Management of
Neurological Emergencies
General Principles
Airway & Breathing
Circulatory Support
Pharmacological Intervention
Psychological Support
Transport Considerations
26. Stroke & 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 HTN, prior stroke, or TIA.
Symptoms and their progression.
27. Stroke & Intracranial
Hemorrhage
Management
Scene safety & 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.
30. 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.
31. Seizures
Assessment
Differentiating Between Syncope & Seizure
Bystanders frequently confuse syncope and
seizure.
32. 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
33. Seizures
Management
Scene safety & BSI.
Maintain the airway.
Administer high-flow
oxygen.
Establish IV access.
Treat hypoglycemia
if present.
Do not restrain the
patient.
Protect the patient
from the
environment.
Maintain body
temperature.
34. Seizures
Management
Position the
patient.
Suction if
required.
Monitor cardiac
rhythm.
Treat prolonged
seizures.
Anticonvulsant
medication
Provide a quiet
atmosphere.
Transport.
35. 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 25g 50% dextrose if hypoglycemia is present.
Administer 5–10mg diazepam IV.
Monitor the airway closely.
36. 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.
37. Syncope
Management
Scene safety & 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.
38. 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 lasts 1–4 hours.
39. Headache
Types
Tension
Organic
Occurs 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.
40. Headache
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?
41. Headache
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.
42. “Weak and Dizzy”
Assessment
Symptomatic of Many Illnesses
Focused Assessment
Include a detailed neurological exam.
Specific signs and symptoms:
• Nystagmus
• Nausea and vomiting
• Dizziness
43. “Weak and Dizzy”
Management
Scene safety & BSI.
Maintain airway & administer high-flow oxygen.
Position of comfort.
Establish IV access & monitor cardiac rhythm.
Determine blood glucose level.
Consider medication.
Antiemetic
Transport and reassure patient.
44. Neoplasms
Tumors
Benign
Malignant
Assessment
Signs & 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
45. Neoplasms
History
Surgery, chemotherapy, radiation therapy, or holistic
therapy
Experimental treatments
Management
Scene size-up and BSI.
Maintain airway & administer high-flow oxygen.
Position of comfort.
Establish IV access and monitor cardiac rhythm.
Consider medication administration.
Analgesics, antiseizure meds, anti-inflammatory meds
Transport and reassure patient.
46. Brain Abscess
Abscess
Collection of Pus
Assessment
Signs & Symptoms
Lethargy, hemiparesis, nuchal rigidity
Headache, nausea, vomiting, seizures
Management
Similar to Neoplasm
47. 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
49. 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.
50. Back Pain & Nontraumatic
Spinal Disorders
Low Back Pain
Causes
Disk Injury
Vertebral Injury
Cysts & Tumors
Other Causes
51. Back Pain & Nontraumatic
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.
52. Summary
Anatomy & Physiology
Pathophysiology
General Assessment
Management of Nervous System
Emergencies
Notas del editor
In resting state, neuron is positively charged on outsied and negatively charged on inside. Similar to heart, when stimulated, Na+ rapidly enters the cell and K- leaves resulting in a loss of charge or Depolarization When the charge reaches the synapse, releases neurotransmitter Acetylcholine for parasympathetic and voluntary (somatic) Noreepinephrine for sympathetic
Remember the dura matter Arachnoid membrane Pia matter
Alt mental is sign of CNS injury or illness (ie coma) Toxic metablic states can be caused by Anoxia Diabetic Ketoacidosis Hepatic Failure Hypoglycemia Renal Failure Toxic exposure Other causes include stroke, hypertensive encephalopathy
Peripheral neuropathy is a malfunction or damage resulting in muscle weakness, loss of sensation, impaired reflexes, and internal organ malfunctions Mono – caused by local conditions such as trauma or infection Poly – demyelination or degeneration, immune disorders, toxic agents, metabolic disorders example – diabetes is a major cause of peripheral neuropathy to hands and feet sometimes called stocking and glove
Appearance Is the patient concious? Alert? Confused? Sitting upright? Speech Can the pt speak? Coherant? Full sentances? Slurred speech Skin Color, temp, moist Facial Droop Posture/gait
History – may be difficult to obtain due to pt alt ment. Obtain info from family. Trauma – mechanism of injury, when di it happen, LOC, incontinence, Medical – underlying med problem ie cardiac, seizures, diabetes, hypertension, has this occurred before. Environmental clures is curent meds, ETOH or dugs, chemicals hazmat Physical Exam Face – ask pt to smile and frown or show me your teeth, note any drooping or paralysis. Eyes – unilateral dilated pupils may result from increased intracranial pressure, bilateral dilated and non reactive is probably caused by brainstem injury. Constricted or pinpoint suggest toxic etiology. Check for contact lense and
Resp paterns – not as reliable Chyne stokes – Kussmals – Diabetic CNS Ataxic – CNS Hyperventilate pt to reduce PaCO2 and cause vasoconstriction reducing intracranial pressure
Sensorimotor exam Pms Decorticate posturing – flexed arms and wrists Decerebrate – extended arms and wrists, both signs of brainstem injury Muscle tone, strength, coordination and balance
Vitals signs Cushing’s Reflex – increased intracranial pressure Initial – pulse decrease BP increase Late – pulse increase BP decrease with increased body temp
Geriatric considerations – use family and staff to evaluate usual mentation
Alt Ment A – Acidosis, alcohol E – Epilepsy I – Infection O – Overdose U – Uremia (kidney failure) T – Trauma, tumor I – Insulin P – Psychosis, Poison S – Stroke, seizure Assessment – AVPU, use bystanders and family to evaluate and determine underlysing cause, perform physical exam to uncover any hidden injuries Management – protect airway using spinal precautions, support ventilations using suplemental oxygen obtain vitals, pulse and BP place on monitor establish IV Treatable causes determine blood glucose – “hyperglycemia produced by administration of glucose will do limited harm in the short tim before arrival at the hospital.” Narcan prn Thiamine – wernicke’s syndrome and korsakoff’s psycosis Mannitol – osmotic diuretic for increased intracranial pressure
Wernicke’s Sydrome – caused by thiamine deficiency, characterized by encephalopathy, irreversible memory loss, disorientation, etc. Hyperventilation reduces intracranial pressure by reducing CO2. Manitol is an oncotic diuresis, which reduces brain swelling.
Stroke – Brain Attack, tPA must be administered within 3 hours Occlusive stroke Embolic – may c/o severe head ache Thrombotic – s/s develop slowly Hemorrhagic – acute onset co/ headache Intracerebral Subarachnoid
Distinguishing TIA Transient Ischemic Attack – may last for several hours, usually resolves in 24. History of disease
Causes Hypoxia Hypoglycemia Febrile Tumors Eclampsia Idiopathic epilepsy – epilepsy means the potential to develop seizures without known cause Generalized Seizures Tonic-Clonic (Grand Mal) seizures Aura LOC Tonic – muscle contraction Clonic – muscle spasm Postictal – confused During seizure, teeth remain clenched. Diaphragm is paralyzed and pt may becom cyanotic. Pt may be incontinent. Absence (Petit Mal) – short term LOC. Usually occur under 20 years of age Pseudoseizers Simple Partial Seizure (focal motor) may not involve LOC Complex partial seizure (psychomotor seizure) distinctive auras, originating in the temporal lobe
Continuous Headaches may be a sign of Meningitis – Particularly if they also complain of Fever Confusion Neck stiffness Nausea and vomiting Rash
Have they had any medication changes Include resp cardio endocrine evaluation
Usually progressive MD – a group of genetic diseases characterized by progressive muscle weakness and degeneration. MS - demyelination of nerve fibers, caused by autoimmune disease. Onset begins in 20 to 40s Dystonias – muscle contraction that cause twisting or repetitive movements. Or freezing in action
Parkinson’s is a motor system disorder which causes shaking, shuffling gaitg, rigidity or resistance to movement, bradykinesia is slowed movement. Bell’s Palsy – facial paralysis of unknown cause, recover within 3 months Lou Gehrig’s – Amyotriphic Lateral Sclerosis (ALS) – degenration of nerve cells that control voluntary movement. Eventually weakens the diaphragm which leads to breathing problems pulmonary infection and death. Polio – Poliomyelitis – infectious inflammatory viral disease of CNS that can result in paralysis.