Chapter 18 Neurologic Emergencies National EMS Education Standard

Chapter 18 Neurologic Emergencies

National EMS Education Standard Competencies Medicine Integrates assessment findings with principles of epidemiology and pathophysiology to formulate a field impression and implement a comprehensive treatment/disposition plan for a patient with a medical complaints.

National EMS Education Standard Competencies Neurology • Anatomy, presentations, and management of − Decreased level of responsiveness • Anatomy, physiology pathophysiology, assessment and management of − − Stroke/transient ischemic attack Seizure Status epilepticus Headache

National EMS Education Standard Competencies Neurology (cont’d) • Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of − Stroke/intracranial hemorrhage/transient ischemic attack − Seizure − Status epilepticus − Headache − Dementia − Neoplasms − Demyelinating disorders

National EMS Education Standard Competencies Neurology (cont’d) • Anatomy, physiology, epidemiology, pathophysiology, psychosocial impact, presentations, prognosis, and management of (cont’d) − − − − Parkinson’s disease Cranial nerve disorders Movement disorders Neurologic inflammation/infection Spinal cord compression Hydrocephalus Wernicke encephalopathy

Introduction • Three of the top 15 causes of death in 2007 were neurologic in nature. − Prevalence: number of people in a given population with a particular disease − Incidence: number of people diagnosed with a particular disorder in a one-year period

Introduction

Introduction • Patients may be in danger. − − − Eyelids do not blink. Larynx does not cause gagging and coughing. Body does not seek a position of comfort. Tongue goes slack. Airway is at risk.

Structure of the Nervous System • Two major structures − Brain − Spinal cord • Responsible for fundamental functions

Structure of the Nervous System • Major structure divided into two categories: − Central nervous system • • Thought Perception Feeling Autonomic body functions − Peripheral nervous system • Communication between the brain and the body

© Jones & Bartlett Learning Structure of the Nervous System

The Brain • Lobes − Occipital lobe: scans through images − Temporal lobe: attaches image to name − Frontal lobe: controls voluntary motion • Efferent nerves: convey commands to the body • Afferent nerves: send signals of discomfort − Parietal lobe: perceives touch and pain

The Brain © Jones & Bartlett Learning

The Brain • Diencephalon and brainstem − Diencephalon: filters out unneeded information − Brainstem • Midbrain: regulates level of consciousness • Pons: controls respiratory pace and depth • Medulla oblongata: controls blood pressure and pulse rate

The Brain

The Brain • Hypothalamus and pituitary gland − Limbic system: generates rage and anger − Hypothalamus: Controls pleasure, thirst, hunger • Communicates to the pituitary gland to send messages to the adrenal glands • Adrenal glands release epinephrine and norepinephrine.

The Brain • Cerebellum − Located in posterior, inferior area of the skull − Manages complex motor activity − Learned behaviors are transferred from the frontal lobe.

Neurons and Impulse Transmission • A neuron contains: − Cell body − Axon: projection extending toward another cell − Axon terminal: where neurotransmitters are made − Dendrites: Carry signals toward the nucleus

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

Neurons and Impulse Transmission

Patient Assessment • The brain is sensitive to change in temperatures and levels of oxygen and glucose. • The brain is resilient to internal environmental changes.

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

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.

Scene Size-up • Gather basic information about the call. − Determine if you need additional resources or equipment. − Determine number of patients. − Ensure that you have the correct PPE.

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 • 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. − 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 Assessment • Circulation (cont’d) − Evidence of ICP: • • Cushing reflex Decorticate posturing Decerebrate posturing Biot’s respirations Apneustic respirations Cheyne-Stokes respirations Anisocoria

Primary Assessment • Circulation (cont’d) − Establish vascular access. − Consider drawing blood samples. − Check blood pressure and pulse rate. • Target systolic pressure: 110 to 120 mm Hg − Perform continuous heart monitoring.

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. • Diastole falls. • Ability to control respiratory and pulse rates is damaged.

Primary Assessment • Transport decision − Consider how to transport: • Complete a rapid secondary assessment. • Complete a secondary assessment and evaluate only the area(s) of patient complaint(s).

Primary Assessment • Transport decision (cont’d) − A rapid exam should be performed with: • An abnormal assessment • A significant MOI/NOI • Any patient you suspect may have a major problem − A secondary assessment is appropriate if the patient is stable.

History Taking • If stable, obtain history. − Ask what happened. − Look for signs and symptoms. − Evaluate the patient’s speech.

History Taking • If patient has had a seizure: − Look for obvious explanations. • For headache, determine: − The patient’s level of stress − The likelihood of infection − History of headaches

History Taking • If responsive, obtain a SAMPLE history. − If first seizure: • Suspect a grave condition. • Determine whether the patient takes medications that lower the blood glucose level. • Inquire about drug use and exposure to toxins.

Secondary Assessment • Head − DCAP-BTLS? • Neck − − − DCAP-BTLS? Symmetry? Masses? Is the trachea midline? JVD? Vertebrae aligned? • Chest − − − DCAP-BTLS? Symmetry? Equal rise and fall? Evaluate ECG Respiratory distress/effort? − Lung sounds? − Determine pulse oximeter reading.

Secondary Assessment • Abdomen − − DCAP-BTLS? Masses? Pulsations? Nausea/vomiting? • Pelvis − DCAP-BTLS? − Stability? − Incontinence? • Extremities − DCAP-BTLS? − Examine pulses, motor function, sensation − Edema? − Venipuncture marks? • Back − DCAP-BTLS? − Ensure curves are in correct place.

Secondary Assessment − Ptosis: the dropping sagging, or prolapse of a part of the body © Dr. P. Marazzi/Photo Researchers, Inc. • Note the symmetry of the face.

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 Courtesy of Chuck Sowerbrower, MED, NREMT-P • Fingernail pressure • Pressure to the supraorbital foramen

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 • Common reality − Hallucinations: feelings of sound, sight, touch, and taste that are entirely within patient’s mind − Delusions: Thoughts or perceived abilities are not based in a common reality.

Secondary Assessment • Common reality (cont’d) − Psychosis: inability to determine what is real and what is inside patient’s mind • Ensure your safety. − Medication may be needed to help manage.

Secondary Assessment • Other changes − Ask patient how he or she feels. − Ask patient how easy it is for him or her think.

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 • Cranial nerve functioning − Abnormal functioning may occur with stroke, trigeminal neuralgia, or myasthenia gravis.

Secondary Assessment

Secondary Assessment • Speech − Agnosia: inability to name common objects − Apraxia: inability to know how to use objects − To test for these signs: • Show patient an object and ask for the name. • If patient responds correctly, ask how to use the object.

Secondary Assessment • Speech (cont’d) − Receptive aphasia: inability to understand speech with ability to speak clearly − Expressive aphasia: inability to speak clearly with ability to understand speech − Global aphasia: inability to follow commands or answer questions

Secondary Assessment • Hemiparesis and hemiplegia − Hemiparesis: weakness of one side of the body − Hemiplegia: paralysis of one side of the body − Decussation: the crossing of nerves as they leave the cerebral cortex

Secondary Assessment • Hemiparesis and hemiplegia (cont’d) − 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 and posture − Gait: walking patterns − Ataxia: alteration of ability to perform coordinated motions − Assess by asking patient to walk several steps. • Posture may become rigid.

Secondary Assessment • Bizarre movement − Myoclonus: rapid, jerky muscle contraction that occurs involuntarily − Dystonia: a part of the body contracts and remains contracted

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 • Blood glucose level − Normal reading is 60 to 120 mg/d. L. − Below 10 mg/d. L 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.

Secondary Assessment • Vital signs (cont’d) − If hypothermia or hyperthermia is suspected, use a thermometer to establish temperature. • Avoid the axillary method. • If unable, gather information about the NOI. • Do not actively rewarm or cool patients.

Reassessment • 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)

Reassessment • Administration of dextrose 50% (cont’d) − If extremely malnourished, first give thiamine − If IV access cannot be obtained, administer 0. 5 to 1 mg of glucagon.

Reassessment • Administration of dextrose 50% (cont’d) − If unresponsive or decreased LOC: • Administer 12. 5 g (1/2 syringe) of dextrose 50%. • Reassess. • Proceed with additional dextrose cautiously.

Reassessment • Airway management − Provide oxygen, ventilation, and protection. − Ensure that pulse oximeter reading is 95% or better. − Provide oxygen and ventilatory assistance as needed.

Reassessment • Airway management (cont’d) − 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.

Reassessment • Administration of naloxone − Used for unresponsive/unknown patients or those with suspected narcotic overdose − Initial dose is 0. 4 to 2 mg IVP. − Can result in rapid change in LOC

Reassessment • Administration of naloxone (cont’d) − Ensure airway and adequate BLS ventilation. • Do not immediately intubate. • Establish an IV line and administer. • After administering, intubation may be needed.

Reassessment • Rectal administration of diazepam − Dose is 0. 2 mg/kg. − Take standard precautions. − Draw up dose, then remove and dispose of needle.

Reassessment • Rectal administration of diazepam (cont’d) − Attach an angiocatheter to the end of the syringe; remove and dispose of the needle. − Insert the plastic catheter into the rectum. − Inject the medication and remove the catheter. − Hold the buttocks together for 5 minutes.

Reassessment • 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

Reassessment • Communication and documentation (cont’d) − Document: • • • 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

Reassessment • Communication and documentation (cont’d) − 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

Reassessment • Communication and documentation (cont’d) − When documenting interventions include: • Time of each intervention • How the patient responded • What the findings showed

Common Neurologic Emergencies • Most diseases or conditions are caused by more than one factor. − Disease susceptibility is often related to: • 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: − − Small tears occur within the arterial wall. Blood enters between the layers of the artery. Pressure builds up, and the tear increases. If damage is severe, the artery can leak or fail.

Pathophysiology of Stroke • Ischemic 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

Pathophysiology of Stroke • Hemorrhagic stroke − Tend to get worse over time • Bleeding causes increased ICP and brainstem herniation. − Primary symptom: “worst headache of my life”

Pathophysiology of Stroke • When ICP climbs and remains high: − The brain may become ischemic because of a lack of blood supply. • Cerebral perfusion pressure (CPP) begins to fall. − CPP = MAP (mean arterial pressure) – ICP • MAP: 80 to 90 mm Hg

Pathophysiology of Stroke

Pathophysiology of Stroke • When ICP climbs and remains high (cont’d): − 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 Agnosia Apraxia • 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. − Ventilation decreases CO 2 and increases O 2. • Provide ventilatory support at 16 to 20 breaths/min. • Maintain PET CO 2 in high 20 s to low 30 s mm Hg.

Management of Stroke Reproduced with permission, 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. © 2010, American Heart Association.

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. • Cincinnati Prehospital Stroke Scale • Los Angeles Prehospital Stroke Screen

Management of Stroke

Management of Stroke • Standard stroke care includes: − Titrating oxygen therapy to the patient’s need • Maintain an SPO 2 reading of 95% or greater. • Use other techniques to assess need for oxygen. • Complete a fibrinolytic checklist.

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.

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 • 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 • Pathophysiology − Many reasons for a decreased LOC.

Coma • Pathophysiology (cont’d) − History of present illness is vital to determine the underlying cause • Determine when the patient was last seen normal. • Evaluate the speed of onset.

Coma • Assessment − Cognitive effects • Decreasing LOC • Confusion • Hallucinations • Delusions • Psychosis • Difficulty thinking • Sleepiness − Speech effects • Slurred speech • Agnosia • Apraxia • Aphasia − Movement effects • Ataxia • Seizures • Posturing − 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 • Try to determine the cause of the seizure. − Medication compliance − Fever − Low blood glucose level in diabetics

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 Occurs with witnesses 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 • Assessment of partial seizures (cont’d) − Complex partial seizures involve changes in LOC. − Patients typically do not become unresponsive.

Seizures • Management − − − Determine whether trauma is a concern. Do not restrain the patient. Remain calm. Prevent the patient from becoming injured. Do not place anything in the patient’s mouth.

Seizures • Management (cont’d) − − Correct hypoglycemia as needed. Ventilatory assistance may be necessary. Provide emotional support. All patients should be transported.

Seizures • Management (cont’d) − If you are concerned of seizure during transport: • Be prepared to administer diazepam or lorazepam. • Pad cot and rails. • Ensure cot straps are not too tight.

Status Epilepticus • Pathophysiology − 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.

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 B 1 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 © Jones & Bartlett Learning • A parent cell divides into two daughter cells.

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.

Neoplasms • Pathophysiology (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

Neoplasms • Assessment − 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 CO 2 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

Dystonia • Pathophysiology − 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.

− Both illnesses begin with flulike symptoms. − Meningitis may elicit: • Kernig’s sign • Brudzinski’s sign © Jones & Bartlett Learning • Assessment © Jones & Bartlett Learning CNS Infections/Inflammation

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

Hydrocephalus • Assessment (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 © Jones & Bartlett Learning

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 longterm 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.