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Transcript of CNS Disorders
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CNS Disorders
EMS Professions
Temple College
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Pathophysiology of CNS Emergencies
Structural Changes Often due to Trauma but not always Circulatory Changes
Inadequate Perfusion Alterations of ICP
Response to insult
Toxic Metabolic states Alteration to blood chemistry or introduction of toxins
Psychiatric ‘mimicking’
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ICP Review CBF is a factor of CPP & CVR
If CPP , then CBF If CVR , then CBF most likely
CPP = MAP - ICP MAP = Diastolic + 1/3 PP PP = SBP - DBP
PCO2 has greatest effect on CVR Sympathomimetics may CVR
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ICP Review As PCO2 , CVR
Therefore, if PCO2 , CVR Then, as CVR , CBF
Normal ICP < 15 mm Hg As ICP , CPP then CBF Compensation for ICP via MAP
Cushing’s Reflex (Triad) Cushing’s triad with coma indicates possible
herniation
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Altered Mental Status
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Coma A decreased state of consciousness from
which a patient cannot be aroused Mechanisms
Structural lesions Toxic Metabolic states Psychiatric ‘mimicking’
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Brain injury Recall that Brain injury is often
shown by: Altered Mental Status Seizures Localizing signs
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Is unconsciousness itself an immediate life threat?
Loss of airway Vomiting, aspiration
YES, IT IS!
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Altered Mental State
Manage ABC’s Before Investigating Cause!
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Initial Assessment/Management Airway
Open, clear, maintain If trauma or + history, control C-spine
Breathing Presence? Adequacy (rate, tidal volume)? High concentration O2 on ALL patients with altered
mental status Assist ventilations prn
Circulation Pulses? Adequate Perfusion?
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Investigate Cause DERM
D = Depth of Coma E = Eyes R = Respiratory Pattern M = Motor Function
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D = Depth of Coma
What does patient respond to? How does he respond?
Avoid use of non-specific terms like “stuporous”, “semi-conscious”, “lethargic”,
“obtunded”
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D = Depth of Coma
AVPU Glasgow Scale (later)
Describe level of consciousness in terms of reproducible findings
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E = Eyes Pupils
Size - mid, dilated or constricted measurement - e.g. 4 mm
Shape - round, oval, pontine Equality - equal in size Symmetry - equal in reaction/response Response to light
Yes or No How?
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R = Respiratory Pattern
Depth Unusually deep or shallow?
Pattern Regular or Unusual pattern
Can you identify the pattern?
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M = Motor Function Paralysis?
Where? Muscle tone?
Rigid or Flaccid Movement?
Where? What is it like? Posturing?
How? Symmetrical Motor Function?
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Physical Exam Vital Signs
Shock? Increased ICP? Hypoxia/Hypercarbia
Diagnostics Dysrhythmias? Blood glucose Oxygen saturation
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Physical Exam Detailed (Head-to-Toe) Exam
Injuries causing coma? Injuries caused by coma? Clues to the cause
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Probable Causes of AMS Not enough Oxygen Not enough Sugar Not enough blood flow to deliver oxygen, sugar Direct brain injury
Structural Metabolic
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Differentiating AMS Causes Structural
Asymmetrical deficits
Unequal pupils Afebrile History of trauma,
structural abnormality
Often a rapid onset
Metabolic Symmetrical deficits Equal pupils
(? altered function) ? Fever History of metabolic
disorder or illness Rapid onset less
likely
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Management Maintain ABCs Attempt to identify cause Mainstays of therapy
Oxygenation/Ventilation IV fluids appropriate for the patient D50 (if hypoglycemic) Narcan if possibility of opiate OD Flumazenil in known benzo only OD
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AEIOU TIPS
Alcohol Epilepsy Insulin Overdose Uremia
(Metabolic causes)
Trauma Infection Psychogenic Stroke/Syncope
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Cerebrovascular Accident AEIOU TIPS
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Cerebrovascular Accident
Any disease process that disrupts blood flow to a distinct region of the brain
Transient Ischemic Attack (TIA) S/S less than 24 hours without
permanent neuro deficits
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Cerebrovascular Accident 500,000/yr in US 25% die Survivors often socially, financially
devastated $20 billion in medical costs, lost
wages
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Cerebrovascular Accident (CVA)
Pathophysiology Thrombosis (brain itself) Embolus (head, neck or heart) Hemorrhage (within brain) Ischemia (systemic blood flow)
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Predisposing Factors: Modifiable
Hypertension Cigarette smoking Diabetes Mellitus Heart disease Hyperlipidemia Cardiovascular
disease
Chronic atrial fibrillation
Sickle cell disease Polycythemia Hypercoagulability Birth control pill use Cocaine use
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Predisposing Factors: Unmodifiable
Age Gender Race Prior stroke Heredity
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CVA Mechanisms
Ischemic stroke--80 to 85% Hemorrhagic stroke--15 to 20%
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Thrombus Embolus Aneurysm Arrhythmia Hypovolemia
CVA Origin
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Ischemic Stroke Blood vessel occlusion
Thrombosis Embolism
Plaque fragments from carotids Chronic atrial fibrillation Fat particles IV substance abuse particulates
Systemic hypoperfusion Pump failure Hypovolemia
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Ischemic Stroke Syndromes Transient Ischemic Attack (TIA)
Neurological deficits that resolve in 24 hours or less (most in 30 minutes)
Commonly result from carotid artery disease Same symptoms as CVA Often warning sign of impeding CVA 5% risk of stroke per year
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Ischemic Stroke Syndromes Dominant Hemisphere Infarction
Contralateral weakness, numbness Contralateral blurring of vision of half the
visual field in both eyes Difficulty pronouncing words (dysarthria) Difficulty speaking or understanding speech
(dysphasia or aphasia)
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Ischemic Stroke Syndromes Nondominant Hemisphere Infarction
Contralateral weakness, numbness Contralateral visual field cut Neglect of contralateral extremities Constructional apraxia (difficulty drawing
figures like a clock face) Dysarthria Usually NOT dysphasic or aphasic
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Ischemic Stroke Syndromes Vertebrobasilar Syndrome
Involves blood flow to brainstem, cerebellum, and visual cortex
Dizziness, vertigo Diplopia Dysphagia Ataxia, bilateral limb weakness
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Hemorrhagic Stroke 30 to 50% 30-day
mortality Younger patient
population Two subtypes:
Intracerebral, usually 2o to hypertension
Subarachnoid, usually from berry aneurysms
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Hemorrhagic Stroke Syndromes Intracerebral Hemorrhage
Headache, nausea, vomiting precede deficits Patients commonly have decreased LOC with
extreme hypertension Contralateral hemiplegia, hemianesthesia Possible aphasia, extremity neglect depending
on hemisphere involved
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Hemorrhagic Stroke Syndromes Subarachnoid HemorrhageGrade I Asymptomatic or mild headache and mild
nuchal rigidityGrade II Moderate to severe headache, nuchal
rigidity, cranial nerve dysfunction but noother deficits
Grade III Drowsiness, confusion, mild focal deficits
Grade IV Stupor, moderate to severe hemiparesis,possibly early decerebrate rigidity,vegetative response
Grade V Deep coma, decerebrate rigidity,moribund appearance
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CVA Assessment
Presentation of CVA varies with area(s) of brain involved and type of CVA
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CVA Presentation Brain can show injury in only three ways:
Decreased LOC Seizures Localizing signs
Hemiparesis or hemiplegia Dysphasia (Receptive or expressive) Visual disturbances Gait disturbances Inappropriate affect Bizarre behavior Incontinence
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Cincinnati Prehospital Stroke Scale Have patient smile (“Facial Droop”)
Normal: Both sides of face move equally well Abnormal: One side does not move as well as other
Have patient close eyes and hold arms out (“Arm Drift”) Normal: Both arms drift same amount or do not drift Abnormal: One arm does not drift or one drifts down compared to
other or can’t move arms
Have patient say, “You can’t teach an old dog new tricks.” (“Speech”) Normal: Correct words, no slurring Abnormal: Slurs words, uses inappropriate words, or unable to
speak
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Assessment Signs & Symptoms
Ischemic S&S usually of slower onset Hemiparesis or hemiplegia Numbness or decreased sensation of face
or unilateral Altered LOC or coma Convulsions Visual disturbances Slurred or inappropriate speech Headache or dizziness
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Assessment Signs & Symptoms
Cerebral Embolus with rapid onset Emboli from valvular HD or Afib rapid onset Often with an identifiable cause (e.g.
Afib, Valvular heart disease, recent long bone fracture)
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Assessment Signs & Symptoms
Cerebral hemorrhage associated with rapid onset
high mortality rate Often with severe HA (“Worst headache
ever”) N/V Rapid decrease in LOC or seizure Coma, Cushing’s and Herniation
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Assessment History Associated Altered LOC or Seizure? Onset/Precipitating factors? Initial symptoms and progression?
Dizziness, Severe HA, N/V Previous CVA or TIA? Previous neuro deficits? Concomitant illnesses?
Sickle Cell Disease Atrial fibrillation
Risk factors for stroke & thrombus formation? BCP, Smoking HTN, CVD
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Assessment Physical Exam
Mental Status & Behavior Extremity Motor & Sensory
Gait Pupils & Vision Cincinnati Prehospital Stroke Scale Evidence of Cushing’s or Herniation Blood glucose level
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CVA Management
Basic ObjectiveImprove cerebral blood flow
and oxygenation
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CVA Management Airway
If no gag reflex, intubate Otherwise, position to ensure drainage of
secretions Suction prn
Breathing Oxygen via NRB Ventilate with BVM and O2 if rate or tidal volume
inadequate Intubate if herniating
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CVA Management Controlled hyperventilation if intracranial
hemorrhage suspected with increased ICP and neurologic deterioration
Indicators Sudden onset Headache Rapid loss of consciousness Seizures Unequal pupils
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CVA Management Circulation
Check blood glucose level Hypoglycemia may mimic CVA Treat hypoglycemia with D50
Establish IV Access Draw blood samples TKO avoid solutions with glucose
Monitor ECG 10% of CVAs are associated with cardiac event 12 Lead ECG if suspected ischemia
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CVA Management
Do not assume patient cannot understand because they cannot talk
Position appropriately: If hypertensive, semireclined (head slightly
elevated) If normotensive, on affected side If hypotensive, supine
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CVA Management Increased Blood pressure treated ONLY
if strongly suggestive of ischemic stroke If systolic >220 or diastolic >120 consider
gradual blood pressure reduction Labetalol Nitropaste Nitroprusside
Controlled reduction Return to pre-CVA levels, NOT to “normal”
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CVA Management Thrombolytic agents
Consider for all patients with ischemic CVA presenting within 3 hours of onset
Early recognition of ischemic stroke and administration of thrombolytics can prevent/limit loss of neurologic function
Requires CT scan!!!
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CVA Management Think like AMI of the Brain
Time is tissue Therapy Mainstays
Oxygenation/Ventilation IV Access Rapid assessment & differential
Treat associated conditions (hypoglycemia, hypoxia, hypotension)
Rapid Transport to appropriate facility CT Scan & Thrombolytics vs. CT Scan &
Neurosurgery
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SyncopeAEIOU TIPS
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Syncope aka Fainting Pathophysiology
Brief loss of consciousness caused by transient cerebral hypoxia
May be caused by lack of glucose or seizure activity in the brain
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Syncope Types
Postural Inadequate blood flow to brain due to
position Vasovagal
Excessive vagal stimulation Carotid Sinus stimulation/pressure
Cardiogenic Dysrhythmia, usually bradycardia Stokes-Adams Syndrome
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Syncope Types
Tussive “coughing spell” resulting in
intrathoracic pressure causing venous return to the heart
most often in overweight male smokers with chronic bronchitis
Micturation associated with urination, usually in
patients who have consumed EtOH and compounded by increased vagal stimulation
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Syncope Assessment
History of the event Often preceded by sensation of light-
headedness Rapid return of consciousness is most
common
Past History History of vertigo Similar past episodes
Many possible causes
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Syncope Management
Manage ABCs Clear airway and Assist ventilations as
needed Oxygen NRB (initially) Calm & Reassure Assess for underlying cause
ECG Blood glucose History (present and past) Physical Exam
Treatment based on underlying cause
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SeizuresAEIOU TIPS
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Seizures Alteration in behavior/consciousness 2°
unstable, uncoordinated electrical activity in the brain Often a result of altered membrane
permeability Manifested by sudden, brief episodes of:
altered consciousness altered motor activity altered sensory phenomena unusual behavior
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Seizure Categories Generalized
Tonic-Clonic (grand mal) AKA Convulsions
Absence (petit mal) Partial
Simple partial Complex partial
Hysterical
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Seizure Etiology CVA Hypoxia Infection/Fever Drug/alcohol
withdrawal Poisoning/OD Thyrotoxicosis
Head trauma Hypoglycemia Brain neoplasms Psychiatric
disorders Eclampsia Hypocalcemia
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Seizures Etiology
Most epileptic seizures are idiopathic in origin
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Generalized Seizures
Petit Mal Absence Sz Children No LOC
Grand mal aka Convulsions Common Often w/Aura Sudden LOC Tonic / Clonic Postictal phase Status epilepticus
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Generalized Seizures
Symmetrical No local onset Irritable focus difficult to identify
Near simultaneous activation of entire cortex
Focus may begin deep in brain and spread outward
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Generalized Seizures Tonic-Clonic Seizures (Grand Mal)
Aura (preictal phase) Loss of consciousness/postural tone Tonic phase Hypertonic (tetanic) phase Clonic phase Post-ictal phase May experience transient neurologic deficits
(Todd’s paralysis)
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Generalized Seizures Absence Seizure (Petit Mal)
Brief loss of awareness (10 - 30 seconds) Usually no loss of postural tone May occur 100+ times a day Primarily pediatric problem Often described as “daydreaming”, not
paying attention Usually disappear as child matures
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Partial Seizures
Seizure begins locally May remain localized or spread to
entire cortex Result from focal structural lesion
in brain
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Partial Seizures Simple
Localized clonic activity
Abnormal sensory symptoms
Usually no LOC May progress
Jacksonian March (Seizure)
Complex Change in
behavior Preceded by aura Repetitive motor
behavior No recall May progress
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Partial Seizures
Simple partial seizures (No loss of consciousness) Focal motor seizures
Local clonic activity May display Jacksonian march
Sensory seizures Autonomic seizures
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Partial Seizures Complex partial seizure (psychomotor or
temporal lobe seizures) Distinctive aura Loss of consciousness Automatisms May be mistaken for drunks or
psychotics May experience episodes of rage
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Hysterical “Seizures” Usually in front of audience Usually follow interpersonal stress Movements asymmetrical or purposeful Does not fall, hit head, bite tongue Incontinence rare Recalls things said, done during
“seizure”
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Assessment Seizure Assessment
Duration Seizure Postictal phase Typical for the patient?
Onset Events before HA Aura Trauma Vision Disturbances
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Assessment Recent History
Trauma to the head/brain HA / Neck Pain Pregnancy Brain tumor Recent Infection/Illness CVA Symptoms Introduction of Poisons into body
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Assessment Past History
Diabetes Mellitus Seizure Disorder Tumor CVA Medications Recreational Drug Use Alcohol abuse
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Assessment Physical Exam
Evidence of trauma Evidence of alcohol, drug abuse Rash, stiff neck Pregnant CVA Signs Incontinence
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Status Epilepticus Two or more seizures without
intervening conscious period Usually due to medication non-
compliance Management same as for other
Seizures just more aggressive
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Seizure Management Patient actively seizing
Do NOT restrain Do NOT put anything in mouth Oxygen NRB if possible ECG Monitor when possible IV Access
Lg Bore, NS Assess blood glucose
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Seizure Management Patient actively seizing
If hypoglycemic: Assess IV patency FIRST!! Dextrose 50% 12.5 - 25 grams IV push Consider Thiamine 100 mg slow IV push
Diazepam, slow IV administration until seizure stops or until ~ 10 mg
Usually aimed at 2.5 mg doses, one after another
Phenobarbital, 100 mg/min IV push to a total ~390 mg or seizure stops
Barbiturate coma NMB & Intubation
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Seizure Management Current Mainstays of Therapy for Actively Seizing
Patient Diazepam Lorazepam Phenobarbital
“New” Therapy Phosphenytoin
Other Considerations Glucose MgSO4
Paraldehyde Dilantin (phenytoin) 18mg/kg at 25 mg/min
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Seizure Management After seizure stops:
Open -Clear- Maintain airway O2 via NRB Assist ventilations if needed Roll patient onto side protecting head Reassess ABCDs Assess blood glucose Physical Exam and History
Most seizure deaths are due to anoxia
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Seizure Management
If the patient is epileptic, do these
seizures match what is “normal”
for him? Just because the patient is
epileptic, he does NOT have to be
having an epileptic seizure!
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Mandatory Transports First time seizures Seizure patient off medications Change in seizure pattern Associated with trauma Pregnant patient Status epilepticus Associated with increased body temperature
Not always; Seldom in young children Has infection been diagnosed and treatment initiated?
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Insulin: Hypo/Hyperglycemia AEIOU TIPS
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Insulin
Hypoglycemia Hyperglycemia
DKA HHNC
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Insulin Assessment
Medical Alert Tag/Bracelet Evidence of DM Medications Fruity breath odor Signs of repeated SQ injections Blood glucose level (See Endocrine for further assessment)
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Insulin Management
Hypoglycemia Management ABCs: Oxygen/IV/ECG Dextrose 50% (adult), 12.5 - 25 grams IV
push via patent line Consider Thiamine 100 mg slow IV push Dextrose 25% (children), 0.5 - 1 grams
IV push (2-4 cc/kg) via patent line Carbohydrate meal Assess for underlying cause Consider transport
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Insulin Management
DKA/HHNC Management ABCs: Oxygen/IV/ECG Ventilate/Intubate prn Fluid administration titrated to signs of
shock 250 cc boluses and reassess
Consider administration of Regular Insulin (consult medical control)
Assess for underlying cause Transport
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Alcohol AEIOU TIPS
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Alcohol
“Dead drunk” Mixed overdose May be associated with
Head trauma Hypoglycemia
EtOH present in up to 40% of AMS patients
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Alcohol
Is it alcohol or is it something
else?A patient is never “Just
Drunk”
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Alcohol Management
Manage ABCs Clear airway and ventilate as needed Oxygen IV access prn
Assess for other causes of AMS ECG Monitor Blood glucose level History of mixed poisoning or EtOH poisoning Physical exam
Treat other causes
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Overdose/PoisoningAEIOU TIPS
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Overdose/Poisoning Possible Overdose/Poisonings resulting
in AMS Alcohol: Ethanol/Methanol Narcotics Sedative-hypnotics Solvent inhalation Stimulants
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Overdose Assessment
Needle marks? Pupil responses? Slow respirations?
Associated hypotension Odd behavior? Breath odors? Color of oral mucosa, vomitus? History of Recent Drug/Poison use?
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Uremia/Metabolic CausesAEIOU TIPS
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Uremia (Metabolic Causes) Uremia/Renal Failure Hyperthyroidism Hypothyroidism Addisonian Crisis Hepatic Coma/Encephalopathy
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Uremia (Metabolic Causes) Assessment
Med Alert? Patient medications? Physical findings? The Physical Exam and History (recent
and past) are most useful
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TraumaAEIOU TIPS
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Trauma Concussion Cerebral contusion Intracranial hematoma Hypovolemia Hypoxia
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Trauma
Assessment Physical findings?
Evidence of brain injury
History of recent or remote trauma?
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Trauma
Altered Mental Status = Head Injury
Until Proven Otherwise
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Trauma
Head injury severity cannot be evaluated
accurately in presence of shock
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Trauma Management
Manage ABCs Spinal motion restriction if indicated Clear airway and secure prn Ventilate prn Oxygen Establish IV access, NS
Fluid to titrate BP to ~ 90 mm Hg systolic Assess for other causes: ECG, Blood glucose Transport to trauma center
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Infection/FeverAEIOU TIPS
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Meningitis Encephalitis Brain abscess Sepsis Fever
Infection
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Infection Assessment
Headache? Fever? Sore throat? Stiff neck (nuchal rigidity)? Rash? Associated symptoms of systemic
infection
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Infection Management
Infection Control Measures Manage ABCs
clear airway and ventilate prn oxygen IV access prn
Consider acetaminophen for fever fluid / rehydration
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PsychogenicAEIOU TIPS
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Hysterical faking Catatonia
“psychomotor disturbances characterized by physical rigidity, negativism, or stupor”
may occur in schizophrenia, mood disorders or organic mental disorders
Psychogenic
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Psychogenic
Assessment Circumstances?
Events leading up to this point Prior behavior?
Similar past episodes Medications & PMHx
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Assessment & Management of AMS
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Primary Assessment Onset
Mechanism (Kinematics) Preceding S/S
Level of Consciousness AVPU GCS (later)
Airway obstruction or compromise Fluid Unprotected airway (e.g. coma)
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Primary Assessment Ventilatory ability
Adequate Ventilatory rate and depth? Respiratory Insufficiency 2° to ICP? (e.g.
irregular patterns) Cardiovascular compromise
Shock /hypotension /hypovolemia Hypertension
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Primary Assessment Neuro Exam (motor & sensory)
Posturing? Muscle Tone? Pupillary Reflexes? Extraocular Movements? Symmetry
History Present and Recent Past
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Management of AMS Goals:
Airway control/ maintenance Avoid hypoxia
Cardiovascular stabilization Avoid hypotension/shock
Interruption of cerebral injury Fix the root cause problem
Protection from further harm Avoid secondary brain injury
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Other Neurologic Conditions
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Headache Common complaint
Many persons experience regularly ~ 1/3 due to migraine HA May be associated with significant pathology
Characteristics Sudden vs Constant vs Recurring Generalized vs Localized Mild to Moderate to Severe Intensity of Pain
Cause is often unknown
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Headache Vascular
Migraines Last minutes to hours to days Usually very intense, throbbing pain Photosensitivity N/V Often unilateral May be preceded by aura (not common) Occur commonly in women
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Headache Vascular
Cluster Series of headaches Usually last for a few minutes or a few
hours Sudden, intense pain Usually unilateral May be accompanied by nasal congestion,
irritated or watery eye (same side) Occur commonly in men
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Headache Tension
Most common headache Occur regularly Often awake in a.m. and worsens throughout
the day Dull, ache Feels like pressure on neck and/or head
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Headache Organic
Not very common Due to some specific cause (illness/injury) in
the body Tumor Infection Meningitis Hypoglycemia etc.
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Headache Potentially Serious Pathologies
Complaint “Worst headache ever” “It hurts right here” May localize at posterior neck at base of
skull Possible subarachnoid hemorrhage
Concern for possible intracranial hemorrhage
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Neoplasms Less common neoplasm Risk factors
genetic exposure to radiation tobacco use occupational exposure to toxins medications/drugs/poisons diet
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Neoplasms Pathophysiology
Most often a result of metastasis from another cancer (malignant)
Assessment focused on the detailed neuro exam not a diagnosis diagnosis BUT should be
included in the differential dx
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Muscular Dystrophy Genetic disorder Results in degeneration of muscle fibers Types
Duchenne Fascioscapulohumeral Limb Girdle Myotonic
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Muscular Dystrophy Duchenne dystrophy
most common childhood muscular dystrophy
onset usually by age 6 symmetrical weakness and wasting of
first the pelvic and leg muscles then pectoral and proximal upper
extremities progresses and results in early death
usually in adolescence
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Multiple Sclerosis Common demyelinating disorder of the CNS Results in patches of sclerosis (patches) in brain
and SC Occurs primarily in young adults Typical S/S
visual loss, diplopia nystagmus weakness, paresthesias symptoms may have periods of exacerbation and
remission
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Parkinson’s Disease Degenerative changes in the basal ganglia
result in deficiency of dopamine Characterized by rhythmical muscular
tremors, rigidity of movement, and droopy posture
Usually occurs after 40 years of age Leading cause of neuro disability > 60 years Estimated 500,000 in US
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Central Pain Syndrome Known as Trigeminal Neuralgia paroxysmal bursts of pain in one or more
branches of the trigeminal nerve Often induced by touching trigger points in or
about the mouth Causes
tumor some medications (phenothiazines)
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Bell’s Palsy Paresis or paralysis of the facial muscles
usually unilateral Occurs in 23 of 100,000 persons Caused by dysfunction of the 7th cranial nerve
cause is usually a viral infection other causes
post trauma herpes simplex lyme disease idiopathic
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Amyotrophic Lateral Sclerosis
Progressive motor neuron disease aka ALS or Lou Gehrig disease disease of the motor tracts of the lateral
columns and anterior horns of the SC results in progressive muscular atrophy, increased
reflexes, and spastic irritability of muscles
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Spina Bifida
An embryolgic failure of fusion of one or more vertebral arches results in spinal cord exposure spinal cord may protrude outward various types based upon type of deformity
Child requires frequent surgeries increased risk of latex allergies
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Poliomyelitis
An inflammatory process of the Spinal Cord’s gray matter
May be caused by the poliomyelitis virus Enters bloodstream and nervous system results in paralysis of the limbs
Uncommon today in the US due to polio vaccine