1. 2 Nervous System Emergencies Chemeketa Community College Paramedic Program.
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Transcript of 1. 2 Nervous System Emergencies Chemeketa Community College Paramedic Program.
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Nervous System Emergencies
Chemeketa Community College
Paramedic Program
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Causes of Coma (We’ll be talking about these…)
• Structural
• Metabolic
• Drugs
• Cardiac (Shock, Arrhythmias, Hypertension,
Stroke
• Respiratory (Toxic Inhalations, COPD)
• Infectious Process (Meningitis)
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And these…..
• Amyotrophic lateral sclerosis (ALS)
• Muscular Dystrophy
• Bell’s Palsy
• Multiple Sclerosis
• Parkinson’s
• Peripheral neuropathy
• Central pain syndrome
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The nervous system
• CNS – 43 pairs of nerves– Brain
• 12 pairs of cranial nerves
– Spinal cord • 31 pairs of spinal nerves
• PNS
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• Neurons– Dendrites, soma, axon,
synapse• Neurotransmitters
– Acetylcholine, norepi, epi, dopamine
• Skull - brain• Spine - spinal cord• Meninges
– Dura mater, arachnoid membrane, pia mater
• Cerebrospinal fluid
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Brain
• Cerebrum
• Frontal lobe
• Temporal lobe
• Parietal lobe
• Occipital lobe
• Cerebellum
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Brainstem• Brain stem
– Medulla– Pons– Midbrain– Reticular formation
• Diencephalon– Hypothalamus– Thalamus– Limbic system
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Blood supply to brain
• Vertebral arteries– Through foramen magnum – Cerebellum– Basilar artery – pons and cerebellum, cerebrum
• Internal carotid arteries– Carotid canals– Anterior cerebral arteries – Frontal lobes, lateral cerebral cortex, posterior cerebral
artery
• Circle of Willis
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Ventricles
• Lateral ventricle
• Third ventricle
• Fourth ventricle
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Spinal Cord
• 17-18 inches long!! To first
lumbar vertebra
• Reflexes
• Afferent - sensory
• Efferent - motor
• Interneurons - connecting
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Peripheral Nervous System
• Cranial nerves
• Somatic sensory
• Somatic motor
• Visceral sensory
• Visceral motor
• Brachial plexus
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Cranial nerves“Some say marry money, but my
brother says bad boys marry money."
• I Olfactory– smell
• II Optic– vision
• III Oculomotor– Constriction,
movement
• IV Trochlear– Downward gaze
• V Trigeminal– Facial sensation,
chewing
• VI Abducens– Lateral eye movement
• VII Facial– Taste, frown, smile
• VIII Acoustic– Hearing, balance
• IX Glossopharyngeal– Throat, taste, gag, swallowing
• X Vagus– Larnx, voice, decreased HR
• XI Spinal Accessory– Shoulder shrug
• XII Hypoglossal– Tongue movement
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Learn the cranial nerves
• On Olfactory• Old Optic• Olympus Oculomotor• Towering Trochlear• Top, Trigeminal• A Abducens• Finn Facial• And Acoustic
• German Glossopharyngeal
• Viewed Vagus• Some Spinal
Accessory• Hops Hypoglossal
OR……
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Autonomic Nervous System
• Sympathetic
– Fight or Flight
• Parasympathetic
– Feed or Breed
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Initial Assessment Be organized and systematic
• Mentation• Ensure patent airway• Spinal precautions prn• Monitor for respiratory arrest, vomiting• Oxygenate• If ventilating with BVM, use NORMAL rate
– PCO2
– SaO2
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Assessment – HistoryBe organized and systematic!
• General health
• Previous medical conditions
• Medications
• History with complaint• Bystanders / Family
– Length of Coma, Sudden or Gradual Onset, Recent Head Trauma, Past medical hx, alcohol/drug use or abuse, complaints before coma
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What led up to 9-1-1?
• Time of onset
• Seizure activity
• Environment
• Cold, hot, drug paraphernalia
• Medications / Medic Alerts
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Assessment - Physical
• General appearance
• Mentation
– Mood
– Clarity of thought
– Perceptions
– Judgment
– Memory & attention
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Assessment - Physical(cont.)
• Speech
– Aphasia
• Apraxia
• Skin
• Posture, balance and gait
• Abnormal involuntary movements
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Assessment - Physical
• Vital signs
– Hypertension
– Hypotension
– Heart rate (fast, slow)
– Ventilation (rate, quality)
– Temperature, fever
• Cushing’s Triad
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Assessment - Physical(cont.)
• Head / neck
– Facial expression
– Eyes
• Acuity, fields, position &
alignment, iris, pupils,
extraocular muscles
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Assessment – Physical (cont.)– Ears
• Acuity
– Nose
– Mouth
• Odors
• Thorax and lungs
– Auscultate
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Assessment - Physical(cont.)
• Cardiovascular
– Heart rate
– Rhythm
– Bruits
– Jugular vein pressure
– Auscultation
– ECG monitoring
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Assessment - Physical(cont.)
• Abdomen
• Nervous
– Cranial nerves
– Motor system
• Muscle tone, muscle strength, flexion, extension, grip, coordination
• Assessment tools
– Pulse Oximetry, End tidal CO2, Blood Glucose
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Assessment
• Ongoing assessment
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Management• Airway and ventilatory support
– Oxygen
– Positioning
– Assisted ventilation
– Suction
– Intubation
• Circulatory support
– Venous access
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Management(cont.)
• Non-pharmacological interventions
– Positioning
– Spinal precautions
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Pharmacological interventions
• Anti-anxiety agent
• Anti-convulsant
• Anti-inflammatories
• Diuretic
• Sedative-hypnotic
• Skeletal muscle relaxant
• Hyperglycemic
• Anti-Emetic
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Management (cont.)
• Psychological support
• Transport considerations
– Mode
– Facility
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Head to Toe
• Pupils
• Respiratory Status
• Spinal Evaluation
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Pupils
• Cranial nerve III (occulomotor)
• Brain herniation = same side
dilation
• Both dilated = anoxia, brain stem
injury
• Anisocoria = unequal pupil –
normal?
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Cardinal Positions of Gaze• Patient should be able to follow your finger
• Conjugate gaze - structural lesion
– Irritable focus - away
– Destructive focus – toward
• Dysconjugate gaze – brainstem
dysfunction
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Respiratory Status
• Cheyne-Stokes
– Brain Injury
• Central Neurogenic
Hyperventilation
– Cerebral Edema
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Respiratory Status (cont.)
• Ataxic
– CNS Damage = poor thoracic
control
• Apneustic
– Damage to upper Pons
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Respiratory Status (cont.)
• Diaphragmatic
– C-spine
• Kussmaul
– DKA
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Spinal Evaluation
• Tingling (pins & needles)
• Loss of Sensation or Function
• Pain, Tenderness
• Priapism
• Deformity, tight neck muscles
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Spinal Evaluation (cont.)
• Motion, Sensation, Position/each
extremity
• “Gas pedal”, grips
• If unconscious, pain response
• Incontinence, rectal for S-1
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Neurological Exam
• Decorticate Posturing
– Above Brainstem
• Decerebrate Posturing
– Brainstem
• Flaccid
• Babinski’s sign
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Neurological Exam
• Glascow Coma Scale
– Motor, 1 - 6
– Verbal, 1 - 5
– Eye, 1 - 4
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Altered Mental
Status/Coma
• Structural Lesions
– Acute onset
– Unresponsive/asymmetric pupillary response
• Toxic - Metabolic States
– Slow onset
– Preserved pupillary response
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Causes of ComaStructural
• Trauma, Tumor
• Epilepsy, Hemorrhage
• Other Lesions
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Causes of Coma - Metabolic
• Anoxia, Hepatic Coma
• Hypoglycemia, DKA
• Thiamine Deficiency
• Kidney, liver failure
• Seizure
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Causes of Coma - Drugs
• Barbiturates, Narcotics
• Hallucinogens
• Depressants
• Alcohol
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Causes of Coma - Cardiovascular
• Hypertensive Encephalopathy
• Dysrhythmias, Cardiac Arrest
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Causes of Coma - Respiratory
• COPD
• Toxic Gases
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Causes of Coma - Infections
• Meningitis
• Encephalitis
• AIDS Encephalitis
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AEIOU - TIPS
• A = Alcohol, Acidosis
• E = Epilepsy
• I = Infection
• O = Overdose
• U = Uremia
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AEIOU - TIPS
• T = Trauma, Tumor
• I = Insulin
• P = Psychosis
• S = Stroke
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Management
• C-spine
• Airway
• Oxygen
• Hyperventilate if ICP is up???
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Management
• D50 - 25 grams
• Narcan - 2.0 mg
• Thiamine 100 mg
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Seizures
• Behavioral alteration due to
massive electrical discharge.
• Generalized or Partial
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Generalized
• Grand Mal
• Petit Mal
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Partial Seizures
• Simple or Complex (Psychomotor)
• May spread to generalized
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Causes
• Brain Injury, Epilepsy, Tumor
• Hypoglycemia, Hyperthermia
• Eclampsia
• Hypoxia
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Grand Mal (generalized)
• Aura, Loss of consciousness
• Tonic, Hypertonic Phases
• Clonic
• Post-Seizure, Post-Ictal
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Other Types
• Focal Motor - One Area of the Body
• Psychomotor - Auras
• Petit Mal, 10-30 Seconds
• Hysterical - How Do You Tell?
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Management• Good history and physical first
• ABCs
• IV, EKG, BG
• Body Temp, Position on Side
• Suction if needed
• Calm, Quiet
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Status Epilepticus
• Two or More Seizures
• Consciousness Not Regained
• Non-compliance With Meds
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Management of Status Seizures
• 100% O2, BVM
• IV, EKG, BG
• D50, Thiamine (if needed)
• Valium 5-10 mg (or Versed 0.5 – 1.0 mg)
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Coma
• Abnormally deep state of unconsciousness
– Structural lesions
– Toxic metabolic states
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DDXStructural lesions
Commonly asymmetrical neurological signsAcute onsetUnresponsive or asymmetrical pupillary
responses
Toxic-metabolic comaNeurological findings symmetricalComa slow in onsetPreserved pupillary response
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Management
• Supportive
• Prevention
• Medication administration
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Stroke (CVA) - what do they
look like?• Motor, Speech, Sensory Centers
• Altered mentation
• Upper Airway Noises
• Unequal Pupils, Visual Disturbances
• Hemiparalysis / Hemiparesis
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Stroke (CVA)
• Eyes Deviate Away From Paralysis, or
Look Toward Lesion
• Dysphagia
• Dysphasia
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Ischemic or Hemorrhagic??
• Most common• Usually 2ndary to
tumor or atherosclerosis
• Slow onset• Long history• May be assoc. with Af• Hx angina, previous
CVA
• Least common• Usually 2ndary to
aneurysm, AV malformation, HTN
• Abrupt onset• Commonly during
stress• May be assoc. with
cocaine• May be asymptomatic
before rupture
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Transient Ischemic Attacks(TIA)
• Little Strokes, Emboli, Carotid Disease
• Stroke Symptoms Gone in a Day
• Usually Mean a Big One Is on the Way
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Cincinnati Prehospital Stroke Scale
• Facial droop
• Arm drift
• Speech “you can’t teach an old dog new
tricks”
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Management CVA / TIA
• Protect Patient
• ABCs / C-spine
• ETT? BVM? OPA?
• Hyperventilate if unresponsive
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Management CVA / TIA
• CBG, IV, EKG
• Reassure, calm (they can hear, usually)
• Position, Transport
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Headaches
• Tension – Muscle contractions
• Migraines– Constriction, dilation of blood vessels;
seratonin or hormone imbalance?
• Cluster– Bursts; occur during sleep
• Sinus– Allergies or infection/inflammation of
membranes
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Management of H/A• Tension
– Aspirin, acetaminophen, ibuprofen
• Migraines– Beta blockers, calcium channel blockers,
antidepressants, serotonin-inhibitors
• Cluster– Antihistamines, corticosteroids, calcium
channel blockers
• Sinus– Antibiotics, antihistamines, analgesics
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Muscular Dystrophy
• Inherited
• Progressive degeneration of muscle fibers
• Duchenne MD most common (1-2/10,000 male children)
• No Tx
• Death usually from pulmonary infection, before age 21
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Multiple Sclerosis
• Gradual destruction of myelin in brain and spinal cord
• Autoimmune?
• 1/1000 (women 3/2 men)
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Parkinson’s Disease
• Degeneration or damage to nerve cells in basal ganglia; 130/100,000
• Lack of dopamine prevents control of muscle contraction
• Progressive
• Initial; slight tremor in one extremity– Shuffling gait– Untreated, severe incapacity in 5-7 years
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Central Pain Syndrome
• Infection/disease of trigeminal nerve– Paroxysmal episodes of severe unilateral pain
• Lips
• Cheek,
• Gums
• Chin
• Pt usually older than 50
• Trigger point
• Treated with tegratol
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Bell’s Palsy
• Inflammation of 7th cranial nerve
• Sudden onset
• Usually temporary, usually 2ndary to infection including Lyme disease, herpes, mumps, HIV
• 1/60-70
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Bell’s Palsy, cont.
• Sx;
– Eyelid, corner of mouth droops
– Taste may be impaired
• Tx:
– Corticosteroid, analgesics
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Amyotrophic Lateral Sclerosis
• Motor neuron disease
– Pt usually over 50; more common in men
• Sx; first, weakness in hands and arms with
fasciculations
• Late – pt unable to speak, swallow, move
• Awareness, intellect maintained.
• Death usually w/in 2-4 years /p Dx
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Peripheral Neuropathy
• Affects peripheral nervous system incl. Spinal nerve roots, cranial nerves– Diabetes– Vit. B deficiencies– Alcoholism– Uremia– Leprosy– Drugs– Viral infections– Lupus
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Nervous System Emergencies
SUMMARY
• Complex and Varied
• Attention to Assessment
• Attention to Treatment
• Good History and Exam
• Good DocumentationS:\HealthOccupations\EMS\EMT Paramedic\Neuro\Nervous System emergencies.ppt
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