Chapter 29

Neurology

Copyright 2006 Pearson

29-1

Lecture Outline

Introduction
Pathophysiolgy
General assessment findings
Management of nervous system
emergencies

Copyright 2006 Pearson

29-2

Introduction
Nervous system disorders affect
thousands of Canadians each year
Strokes affect 50 000
Epilepsy affects 300 00
100 000 people have been diagnosed with
Parkinsons disease

Copyright 2006 Pearson

29-3

Pathophysiology
Alterations in cognitive systems
RAS
Cerebral cortex

Peripheral nervous systems

disorders
Peripheral neuropathy

Copyright 2006 Pearson

29-4

Central Nervous System

Disorders
Structural lesions
Tumour
Degenerative
disease
Intracranial
hemorrhage
Parasites
Trauma

Toxic-metabolic
states
Anoxia
Diabetic
ketoacidosis
Hepatic failure
Hypoglycemia
Renal failure
Thiamine deficiency
Toxic exposure

Copyright 2006 Pearson

29-5

Assessment
Scene and primary assessment

AVPU
General appearance
Speech
Skin and facial drooping
Mood, thought, perception, judgment,
memory, and attention

Copyright 2006 Pearson

29-6

History

When did the incident occur?

Loss of consciousness?
Incontinence?
Chief complaint?
Changes?
Complicating factors?
Copyright 2006 Pearson

29-7

 Face

Secondary
Assessment

Smile, frown, facial drooping

Eyes
Pupils

Nose/mouth
Potential compromise of the airway

Copyright 2006 Pearson

29-8

Respiratory Status

Copyright 2006 Pearson

29-9

Cardiovascular System
Status

Heart rate
ECG
Bruits
JVD

Copyright 2006 Pearson

29-10

Nervous System
Status
Sensorimotor
evaluation
AVPU
Incontinence
Distal properties

Motor system status

Muscle tone
Strength
Flexion/extension
Coordination
Balance
Copyright 2006 Pearson

29-11

Posturing
Decorticate
Arms flexed, legs extended
Lesion at or above the upper brainstem

Copyright 2006 Pearson

29-12

Posturing
Decerebrate
Sustained extension
Lesion in the brainstem

Copyright 2006 Pearson

29-13

Nervous System
Cranial nerveStatus
status
Glasgow Coma
Scale (GCS)
Eye opening
Verbal response
Motor response

Copyright 2006 Pearson

29-14

Copyright 2006 Pearson

29-15

Additional Assessment
Tools

End tidal CO2

Pulse oximetry
Blood glucose determination

Copyright 2006 Pearson

29-16

Geriatric
Considerations
More susceptible to systemic
illness
Certain changes occur naturally
with aging

Pupil sluggishness
Loss of overall body strength
Muscle atrophy
Altered sensation
Copyright 2006 Pearson

29-17

General
Management
Airway and breathing

Circulatory support
Pharmacological intervention
Psychological support
Transport considerations
Primary treatment is supportive
Copyright 2006 Pearson

29-18

Altered Mental
Status
acidosis

A
E
epilepsy
I infection
O overdose
U
uremia (kidney failure)
T
trauma, tumour, toxin
I insulin (hypoglycemia, ketoacidosis)
P
psychosis, poison
S
stroke, seizure
Copyright 2006 Pearson

29-19

Management

Airway and breathing

Circulatory support
Establish IV
Blood glucose
Treat reversible causes
Hypoglycemia
Narcotic overdose
Copyright 2006 Pearson

29-20

Altered Mental
Status
Chronic Alcoholism
Significant percentage have a thiamine
deficiency
Wernickes Syndrome
Korsakoffs Psychosis

Increased Intracranial Pressure

Hyperoxygenation
Consider mannitol
Copyright 2006 Pearson

29-21

Stroke
Injury or death to brain tissue
Usually due to an interruption in cerebral
blood flow

Physiology compares to an MI
Categories
Occlusive
Hemorrhagic
Copyright 2006 Pearson

29-22

Occlusive Stroke
Cerebral artery blocked by a clot or
foreign matter

Ischemia
Infarction
Tissue swells
Herniation

Copyright 2006 Pearson

29-23

Occlusive Stroke
Embolic stroke
Embolus carried to cerebral blood vessel from a
remote site
Usually clots arising from diseased vessels
Atrial fibrillation

Thrombotic stroke
Blood clot gradually develops in and obstructs a
cerebral blood vessel
Signs develop gradually
Occurs at night, patient wakes up with signs

Copyright 2006 Pearson

29-24

Copyright 2006 Pearson

29-25

Hemorrhagic Stroke
Sudden onset characterized by
headache and decreased LOC
Intracranial
Within the brain
Small blood vessels
Effects depend on location of blood vessels

Subarachnoid
Develops from congenital blood vessel
abnormalities
Copyright 2006 Pearson

29-26

Hemorrhagic Stroke
Hemorrhage inside the brain tears
and separates blood vessels
Impaired drainage of CSF
Herniation of brain tissue occurs
rapidly

Copyright 2006 Pearson

29-27

Copyright 2006 Pearson

29-28

Presentation
Signs

Symptoms

Facial Drooping
Headache
Aphasia/Dysphasia
Hemiparesis
Hemiplegia
Paraesthesia
Gait Disturbances
Incontinence

Confusion
Agitation
Dizziness
Vision Problems

Copyright 2006 Pearson

29-29

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

High risk of thrombotic stroke

Copyright 2006 Pearson

29-30

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.
Copyright 2006 Pearson

29-31

Seizure
Temporary alteration in behaviour
die to massive electrical discharge
from one or more groups of
neurons in the brain
Hypoxia
Decreased blood sugar

Epilepsy
Idiopathic seizures
Copyright 2006 Pearson

29-32

Generalized
Seizures
Tonic-Clonic
Also called grand mal

Aura
Loss of consciousness
Tonic phase
Hypertonic phase
Clonic phase
Postseizure
Postictal
Copyright 2006 Pearson

29-33

Generalized
Seizures
Absence
Also called petit mal
Presents with brief loss of consciousness
May not respond to normal treatment

Pseudoseizure
Usually stem from a psychological
disorder
No post ictal phase
Copyright 2006 Pearson

29-34

Partial Seizures
Simple partial seizures
Involve one body area
Can progress to generalized seizure

Complex partial seizure

Characterized by an aura
Typically 2-3 minutes in length
Loss of contact with surroundings
Copyright 2006 Pearson

29-35

Copyright 2006 Pearson

29-36

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
Physical exam

Signs of head trauma or injury to tongue, alcohol or drug

abuse

Copyright 2006 Pearson

29-37

Management

Scene safety and BSI.

Maintain the airway.
Administer high-flow oxygen.
Establish IV access.
Treat hypoglycemia if present.
Protect the patient from the
environment.
Do not restrain the patient.

Maintain body temperature.

Copyright 2006 Pearson

29-38

Protection of a seizuring
patient

Copyright 2006 Pearson

29-39

Management
Position the patient.
Suction if required.
Monitor cardiac rhythm.
Treat prolonged seizures.
Anticonvulsant medication

Provide a quiet atmosphere.

Transport.
Copyright 2006 Pearson

29-40

Place a seizuring patient

with no spinal injury on her
side

Copyright 2006 Pearson

29-41

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 510mg diazepam IV.
Monitor the airway closely.

Copyright 2006 Pearson

29-42

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

Copyright 2006 Pearson

29-43

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.
Copyright 2006 Pearson

29-44

Headache
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 14 hours.
Copyright 2006 Pearson

29-45

Headache
Tension
Organic
Occurs due to tumours, 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.
Copyright 2006 Pearson

29-46

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?
Copyright 2006 Pearson

29-47

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.

Copyright 2006 Pearson

29-48

Weak and Dizzy

Assessment
Symptomatic of many illnesses
Focused assessment
Include a detailed neurological exam.

Specific signs and symptoms:

Nystagmus
Nausea and vomiting
Dizziness

Copyright 2006 Pearson

29-49

Management
Scene safety and BSI.
Maintain airway and administer high-flow
oxygen.
Position of comfort.
Establish IV access & monitor cardiac
rhythm.
Determine blood glucose level.
Consider medication.
Antiemetic

Transport and reassure patient.

Copyright 2006 Pearson

29-50

Neoplasms
Refers to the growth of a new tumour
CNS neoplasms have a high mortality

Benign
Abnormal growth
Pressure in confined spaces (cranial vault)

Malignant
Infiltrates healthy tissue
Likely to metastasize

Copyright 2006 Pearson

29-51

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

History
Surgery, chemotherapy, radiation therapy, or
holistic therapy
Experimental treatments
Copyright 2006 Pearson

29-52

Management
Scene safety and BSI.
Maintain airway and administer highflow oxygen.
Position of comfort.
Establish IV access and monitor
cardiac rhythm.
Consider medication administration.
Analgesics, antiseizure meds, anti-inflammatory
meds

Transport and reassure patient.

Copyright 2006 Pearson

29-53

Brain Abscess
Abscess
Collection of Pus

Assessment
Signs and symptoms
Lethargy, hemiparesis, nuchal rigidity
Headache, nausea, vomiting, seizures

Management
Similar to neoplasm
Copyright 2006 Pearson

29-54

Degenerative
Disorders
Alzheimers
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
Progressive muscle weakness and degeneration
of muscle fibres

Multiple sclerosis
Unpredictable disease resulting from
deterioration of the myelin sheath
Weakness and sensory loss
Copyright 2006 Pearson

29-55

Degenerative
Dystonia Disorders
Group of disorders
Muscle contractions that cause twisting
repetitive movements

Parkinsons disease
Chronic progressive motor system disorder
Tremor, rigidity, bradykinesia, postural instability

Central pain syndrome

Result of CNS injury
Intense, steady burning pain
Copyright 2006 Pearson

29-56

Degenerative
Disorders
Bells palsy
One-sided facial paralysis
Unknown cause

Amytrophic lateral sclerosis

Degeneration of motor tracts
Weakness, loss of motor control

Myoclonus
Temporary, involuntary twitching of
muscles
Copyright 2006 Pearson

29-57

Degenerative
Disorders
Spina bifida
One or more fetal vertebra fail to close
Portion of the spine left unprotected

Poliomyelitis
Inflammatory, viral disease of CNS tissue
Sometimes results in permanent paralysis

Copyright 2006 Pearson

29-58

Degenerative
Disorders
Assessment
Obtain history.
Exacerbation of chronic illness or new
problem?

Management
Special considerations
Mobility, communication, respiratory
compromise, and anxiety
Copyright 2006 Pearson

29-59

Back Pain and

Nontraumatic Spinal
Disorders
Low Back Pain
Most common back pain complaint
Accounts for greatest amount of lost work time
in Canada

Causes
Degeneration or rupture of discs
Degeneration or fracture of the vertebra
Cyst or tumour that impinges on the spine
Copyright 2006 Pearson

29-60

Assessment and
Management

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.
Copyright 2006 Pearson

29-61

Summary
Pathophysiology
General assessment findings
Management of nervous system
emergencies

Copyright 2006 Pearson

29-62