Download (CEN) Exam Review Jeff Solheim

Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
NEUROLOGICAL EMERGENCIES
Objectives:
At the completion of this section, the learner will be able to:
 Differentiate between early and late signs of increased intracranial p ressure
 Discuss care of the patient with a basilar sku ll fracture
 Define autonomic dysreflexia
 Recognize medicat ions used in the treatment of seizu res
 Verbalize d ischarge instructions that should be provided to patients with Myasthenia Grav is
The CEN exam contains fifteen questions on neurological emergencies which i nvol ve the followi ng topics:
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Alzheimer’s Disease/Dementia
Chronic Neurological Disorders (e.g. Multip le Sclerosis, Myasthenia Grav is)
Gu illain-Barre Syndrome
Headache (including temporal arteritis, migraine)
Increased intracranial pressure
Meningitis
Seizure d isorders
Shunt Dysfunctions
Spinal cord in juries
Stroke (e.g. Ischemic or hemorrhagic)
Transient Ischemic attack (TIA)
Trau ma
 Increased intracranial pressure (ICP)
 Cran ial Vau lt consists of three constituents: brain, cerebral spinal fluid (CSF) and blood.
 Normal ICP: 0 - 15 mm Hg
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
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Elevated ICP: > 20 mm Hg
Extremely high ICP may lead to herniation of the brain.
Clin ical Manifestations of increased intracranial p ressure:
Level of
Consciousness
Pupils
Motor Function
Vital Signs
EARLY S IGNS (Increased ICP)
More stimu lation required to get
same response
Sluggish response to light
Loss of one or mo re grades on the
strength scale
Tachycardia, hypertensive swings
LATE S IGNS (Herniation)
Arousable only with deep
pain or unarousable
Fixed or d ilated
Posturing or no response
Cushing’s response
Definiti on: Cushing’s Triad – Abnormal set of vital signs often associated with
advanced or increased intracranial pressure. Includes:
 Profound bradycardia
 Abnormal respirations
 Increased systolic pressure (widened pulse pressure)
 Treat ment
 Reduce ICP by reducing the constituents of the skull:
Brain


Diuret ics
Hypertonic solutions

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
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Blood
Patient position
Maintain normothermia
Prevent/ treat seizures
Reduce noxious stimuli
Suctioning
CSF Flui d
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
Surgical decompression
CSF drainage catheter
1 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Shunt Dysfunction
Problem
Sympto ms
Obstructed
shunt
Infected
shunt
Overdrainage
o
Signs of  ICP (irritability, headache, neck pain, vo miting, bulg ing
fontanels, new seizures, change in behavior.)
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Signs of obstruction
Local wound problems
Unexplained fevers
Redness, edema and tenderness along skin over the shunt.
Signs of peritonitis (if shunt terminates in the abdomen.)
Depressed fontanels
Overlapping of sku ll bones
 headache when upright,  when supine
Subdural hemato mas
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
Treat ment
As per  ICP for head injury
Flushing of the shunt.

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Antibiotics
Sepsis protocols


Replacement of shunt
Supportive therapy (oxygen, treat
seizures and bleeds as per protocols.
Suction PRN

Glasgow Co ma Scale

Best Motor Response
Obeys simple co mmands
Localizes noxious stimulus
6
5
Flexion withdrawal
4
Abnormal flexion
Abnormal extension
No motor response
3
2
1
Best Verbal Response
Oriented
Confused
Verbalizes, inappropriate
words
Vocalizes – moans/groans
No verbal response
5
4
Eye Opening
Spontaneously
To speech
4
3
3
To noxious stimulus
2
2
1
No eye opening
1
Eyes and pupils
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

Size – pupils should be with in 1 mm in size o f one another.
Anisocoria: pupils that are more
Shape – pupils are normally round. Irregularly shaped pupils, especially oval,
than one millimeter different in size.
indicate dysfunction or pressure on oculomotor nerve III.
Anisocoria occurs normally in as
many as 20 – 25% of patients, and
 Degree of reactivity – both pupils should rapidly constrict when light is shone
is more co mmon with age.
into one of them.
Best motor response
 Assess motor and sensory function or weakness, loss of movement or altered sensation to any part of the body
 Assess for pronator drift in the conscious, cooperative patient: ask the patient to close his or her eyes, and extend the
arms out directly in front of them, ho lding this position for 30 seconds. If one arm drifts downward ahead of the other, it
is an indicator of weakness to that side of the body.
Deficits fro m the neck up affect the same side
as the brain lesion (ipsilateral) and deficits
fro m the neck down affect the opposite side as
the brain lesion (contralateral)
- paresis (such as hemiparesis) indicates
weakness to an area of the body.
-plegia (such as paraplegia) indicates
paralysis to an area of the body.
2 |P age
Certified Emergency Nurse (CEN) Exam Review
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Reflex
Corneal reflex
Gag reflex
Swallo wing reflex

Jeff Solheim
If a patient’s level of consciousness does not allow them to cooperate with assessments, apply painful stimuli and look
for the patient’s reaction. The fo llo wing are listed in order fro m most favorable response to least favo rable response in
terms of outcome:
 Localizing pain – reaching toward the painfu l stimulus
 Withdrawal – mov ing the extremity away fro m the painfu l stimulus
 Decorticate posturing – abnormal flexion posture: the arms, wrists,
and fingers are flexed, the arms are adducted, while the legs are fu lly
Memory Tip – Decort icate has the word
“core” in it and patients maintain a
extended and internally rotated with plantar flexion o f
position with their hands adducted to the
the feet.
core of their body. Decerebrate has
 Decerebrate posturing – abnormal extension posture: the
mu ltip le “e’s” in it and “extension” starts
arms are stiffly extended and abducted, and the hands
with an “e”; Pat ients who are decerebrate
are hyperpronated. The legs and feet remain unchanged
extend their hands away fro m their body.
fro m decorticate posturing.
 Flaccid – no motor response
Superficial reflexes – normal when present, abnormal when absent
Method of Elicitation
Brush a wisp of cotton against the cornea or apply a small
drop of water or saline to the cornea.
Stimu late the back of the pharynx.
Touch the uvula.
Normal Response
The eyelid closes quickly.
The patient retches or gags.
The uvula elevates.
Pathological reflexes – abnormal when present, normal when absent. (These reflexes are normal in in fants, but disappear
in toddlers.)
Reflex
Method of Elicitation
Grasp reflex
Stimu late the palm of an unresponsive patient’s hand.
Babinski reflex
Stroke the lateral aspect of the foot.
 Reflex Tests

Doll’s eyes test (oculocephalic reflex)

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Pathol ogical (Positi ve) Res ponse
The patient closes the fist and grasps.
Great toe extension occurs.
Move the patient’s head briskly to the right or left.
 Normal: patient’s eyes will deviate away fro m the direction the head is rotated.
 Abnormal: Eyes remain midline or move in a dysconjugate manner.
Water Calo ric Test (oculovestibular reflex)

Ice water is injected in the ear.
 Normal: both eyes move in the direction of the side water is instilled.
 Abnormal: Both eyes do NOT move in the direction of the side water is instilled.
 A Glasgow Co ma Score of 13 – 15 is normal or mild brain in jury, a score of 9 to 12 is moderate brain injury and a sc ore of 3
– 8 is profound brain injury.
 Specific Brain In juries
 Diffuse A xonal In jury (disruption of axons in the cerebrum which leads to a disconnection of the cortex and the brain -stem
reticular formation).
 Clin ical Manifestations
 Decorticate or decerebrate posturing
 Loss of brain stem reflexes
 Hypertension
 Hyperthermia
 Excessive sweating
 Treat ment is to decrease ICP and support the patient.
3 |P age
Certified Emergency Nurse (CEN) Exam Review

Jeff Solheim
Intracerebral b leeds
 Ep idural b leed (bleeding between the skull and the dura mater, usually from the midd le meningeal artery)
 Clin ical manifestations are rapid progression of increasing ICP.
Memory t ip – The meninges PAD the
 Patients may have a period of unconsciousness follo wed by a lucid
brain – the letters in PA D can be used
period than begin to lose consciousness again.
to help remember the order of the
 Often co mplain of severe headache, may have hemiparesis and dilated
men inges from brain to the skull
pupil on the side of the injury
Pia is the innermost membrane that
 Subdural bleed (bleeding between the dura mater and the subarachnoid
directly covers the brain.
Arachnoid is the middle layer
mater, usually from small bridging veins)
Dura is the outermost layer closest to
 Clin ical manifestations will be signs of increasing ICP.
the skull.
 Because this bleed is venous, clinical man ifestations are usually slower
to manifest than with an epidural b leed.
 Acute Subdural bleed – sympto ms occur within 48 hours
 Subacute Subdural bleed – sympto ms manifest 2 – 14 days later.
 Chronic Subdural bleed – sympto ms take longer than 14 days to manifest
 Clin ical features are:
 Loss of consciousness
 Hemiparesis
 Fixed, dilated pupils

 These findings are slower onset and less severe in slow onset bleeds.
Subarachnoid bleed
 Signs and symptoms
 Headache
 “worst headache of my life” or “thunderclap headache”
 Unrelieved by conventional therapies
 May complain of “warn ing leaks” in weeks preceding the bleed.
 Nausea and vomiting
 Photophobia
 Sudden seizure
 Meningeal signs (fever, nuchal rigidity)
 Treat ment
 Measures to reduce ICP
 Calciu m channel blockers
 Surgical intervention to control hemorrhage and manage ICP.
\
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Basilar Sku ll Fracture (Fracture at the base of the skull in the anterior, middle or posterior fossa)
 Clin ical Manifestations
Anterior Fossa
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Anosmia
Ep istaxis
Rh inorrhea
Subconjunctival hemorrhage
Hemorrhage in the periorb ital spaces
(Raccoon’s eyes)
Visual d isturbances
Altered eye movement
Ptosis
Loss of sensation to forehead, cornea and
nare
Middle Fossa
•
•
•
•
•
•
Loss of sensation to
lower face
Facial palsy
Deafness
Tinnitus
Hemotympanu m
Otorrhea
Posterior Fossa
•
•
Ecchy mosis
behind the ear
(battle sign)
Impaired gag
reflex
4 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Definiti on – Hal o Test – Allow blood fro m the nose or ear to
drop on a piece of gauze. If CSF flu id is in the blood, a yello w
ring or halo will appear around the outside of the blood drop.
Definiti on: Battle’s sign – bruising in the
mastoid sinus, noted behind the ear. May
take 24 hours post-injury to appear.

Definiti on – Gl ucose test – A llo w clear drainage
fro m the nose to drop on a glucose s trip. CSF
flu id is high in glucose, nasal discharge is not.
Definiti on:
Anosmia– inability
to perceive smells
Definiti on: Raccoon’s sign –
periorbital ecchymosis secondary
to intra-orbital bleeding
Treat ment
 Antibiotics
 Halo test
 Monitor for, and treat, increased intracranial pressure

Avoid:

Nose blowing
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Sneezing
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Nasal cannula
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Dressings
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Nasal intubation
 NG insertion
 Spinal cord in juries
Posterior Cord
transmits:
 Light touch
 Proprioception
 Vibrat ion
Lateral Cord
transmits
 Pain
 Temperature
Anteri or Cord
transmits:
 Motor function
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Lateral nerves cross over low where they enter the spinal cord.
 Anterior and posterior nerves cross over high near the base of the brain.
Co mplete cord injuries
Nerve Level
Muscles innervated
Patient Response
C-4
Diaphrag m
Ventilat ion
C-5
Deltoid, biceps, brachioradialis
Shrug shoulders, flex elbows
C-6
Wrist extensor
Extend wrist
C-7
Triceps
Extend elbow
C-8
Flexo r d igitoru m profundus
Flex fingers
T-1
Hand intrinsic muscles
Spread fingers
T - 2 – L-1
Intercostals
Vital Capacity
L-2
Iliopsoas
Hip Flexion
L -3
Quadriceps
Knee Extension
L-4
Tibilalis anterior
Ankle dorsiflexion
L-5
Extension hallucis longus
Ankle eversion
5 |P age
Certified Emergency Nurse (CEN) Exam Review

Injury
Anterior Co rd
Posterior
Cord
Central Co rd
Syndrome
Bro wnSèquard
Cauda equina
syndrome

Partial cord syndromes
Manifestati on
Loss of motor function, loss of pain, temperature, crude touch and crude pressure.
Intact proprioception, fine touch, fine pressure, and vibration
Loss of proprioception, vibration, fine touch, and fine pressure
Intact motor function, pain, temperature, crude touch, crude pressure
Proportionally g reater loss of motor function in upper extremit ies than lower extremities with variable sensory sparing
(Sensory loss is variable, more likely to lose pain and/or temperature than proprioception and/or vibration )
Loss of motor function, proprioception, and vibration sense on side of injury
Loss of pain and temperature on opposite side of inju ry
Caused by damage to the lower spinal cord. Results in varying degrees of motor and sensory loss in the lower body.
The patient may experience problems with bowel and bladder control (especially urine retention) and sexual function.
Spinal shock versus Neurogenic shock
Definition
Manifestations
o
Jeff Solheim
Spinal shock
Concussion to the nervous tissue of the spinal cord
resulting in temporary loss of sensation and movement.
– Temporary loss of:
– Sensory function
– Motor function
– Reflexes
– Bowel and bladder dysfunction
Neurogenic shock
Loss of sympathetic tone secondary to damage
to the sympathetic fibers of the spinal cord.
– Hypotension
– Bradycardia
– Bradypnea
– Priapism
– Poikilothermy
Treat ment
 Treat neurogenic shock as per shock lesson
 Provide cervical stabilization of the neck and back.

Manual stabilization, C-Co llars/head blocks/ back boards

Maintain align ment in position found, do not force anyone with airway d ifficu lties into align ment

Padding under head of child

Tip backboard of pregnant patient.
 Autonomic Dysreflexia
Sympathetic stimulat ion to
lower part of body secondary
to noxious stimu li (full
bladder, full rectu m, acute
abdomen, decubitus ulcer,
renal calculi, and cystitis)
results in vasoconstriction
below the level of the injury,
forcing blood into the upper
part of the body
Baroreceptors sense
sudden elevation in BP and
turn on parasympathetic
nervous system resulting in
bradycardia and
vasodilation above the
level of the inju ry.
6 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
o
Clin ical Manifestations
 Sudden severe headache
 Hypertension
 Sweating
 Card iac dysrhythmias (tachycardia or bradycardia)
 Flushing above the level of the injury and coolness below the level of the injury
 Nasal stuffiness
 Patient may appear an xious
o Treat ment
 Identify and rectify the cause
 Ganglionic Blockers such as Hydralazine (Apresoline) to reduce blood pressure
 Measures to reduce intracranial pressure
 Headaches
Common Feature
Length of Headache
Type of Pain
Location of Pain
Physical Acti vity
Accompanyi ng
Symptoms
Migraine
Aura (classic)
No Aura (co mmon)
4- 72 hours
Severe, pulsatile, throbbing
Usually unilateral
Aggravated
Photophobia, phonophobia,
facial paleness, nausea and vomit ing
Cluster
Occurs in clusters, seasonal
15 to 180 minutes
Excruciat ing, “suicidal”
Behind one or both eyes
Incapacitated
Facial flushing, nasal congestion, drooping
eyelid, pupillary changes

o
Treat ments
o Migraine headache
 Cold packs
 Darkened room
 Pharmacology (analgesics, anti-in flammatory agents, beta-adrenergic blockers, Serotonin
antagonists, Vasoconstrictors, Anti-depressants, Diuretics, Antihistamines, Steroids.)
o Cluster headache – high flow o xygen
Teaching Points for headache sufferers:
 Women should avoid oral contraceptives
 Avoid the following foods
o Ethanol
o Foods containing tyramines (beer, aged cheeses)
o Caffeinated beverages
o Nitrates (hot dogs, salami, processed meats, ham, bacon, yeast)
o Monosodium g lutamate (packaged soups, chocolate)
 Seizures
Seizures
Seizures
Generalized
Tonic-Clonic
•Tonic phase
•Clonic phase
•Post-ictal phase
Absence
•Ages 4 – 12
•< 15 seconds
•Automatism
Partial
Complex
Simple
Unaware
Aware
•Involves:
•Focal motor activity
•Somatic sensory
experiences
•Disturbances in vision,
hearing, smell or taste
•Usually unilateral
7 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Treat ment
 Airway
 Consider Dext rose 50% and rapid cooling
 Benzodiazep ines to stop seizures
 Anticonvulsants to prevent recurrence
 Phenytoin (Dilantin)
 Never give in dextrose containing solution (give in NS)
 Has a high pH, will cause severe local tissue necrosis in cases of infiltration (g ive antecubital or central line)
 Elevate limb, apply d ry heat and cool compresses after extravasation
 Side effects
 Hypotension
 Heart blocks
 Bradycardia
 Phenobarbital
 Monitor for respiratory suppression, central nervous system depression and hypotension
 Fosphenytoin Sodium (Cerebyx)
 Expensive
 Used for status epilepticus
 Monitor for
 Hypotension
 Depressed respirations
 Meningitis (Infection of the pia or arachnoid meninges)



Causative agents
 Fungus – rare, associated with immu moco mpro mise
 Virus – mild, short lived, non-contagious with gradual onset of symptoms
 Bacteria - life threatening with acute onset of symptoms. Sources include blood, basilar sku ll fractures, infected facial
structures, brain abscesses.
Clin ical Manifestations
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Headache (especially occip ital)
Altered mental status/malaise
Hyperreflexia/seizures
Nuchal rigid ity
Fever and chills
Signs of sepsis (tachycardia, tachypnea, hypotension)


Patients with meningococcal meningit is may present with a non -blanching petechial rash on the torso and legs.
Pediatric specific signs:

Vo mit ing, anorexia, and poor feeding

Altered mental status

High-pitched cry in the infant

Bulg ing of the fontanels

Bradycardia
 Biot’s respirations
Treat ment
 Assume it is bacterial – negative pressure room and masks
 Introduce measures to reduce intracranial pressure
 Assist with lu mbar puncture
 Initiate antibiot ics (may be stopped if viral)
 Admin ister antipyretics and analgesics

Provide prophylaxis for all close contacts of bacterial men ingitis
8 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s disease) (Neurodegenerative disease results in inability of the voluntary
motor nerves to transmit impulses, resulting in loss of motor function and muscle degeneration.)
 Usually starts in one limb and is marked by twitching, cramping, and stiffness of the affected muscles.
 With time, the patient may beco me unstable when walking or have difficulty with fine motor control when writ ing or
buttoning a shirt.
 Ult imately, all limbs are affected, respiratory muscles weaken, respiratory co mplications become co mmon, and the
swallowing muscles may weaken, leading to choking and aspiration. The speech becomes slurred and nasal.
 No cure, supportive therapy only
 Multiple Sclerosis (MS)
 Autoimmune disease which comes in sporadic attacks, brought about by triggers such as viruses, pregnancy, stress, and the
spring and summer seasons.
 An attack can cause blurred or double vision, red-green co lor distortion, blindness in one eye, weakness, and difficu lty with
coordination and balance. Paresthesia, pain, speech impairment, tremors, and dizziness also may occur.
 The first attack typically occurs between ages 20 and 40.
 The symptoms of an attack may resolve completely, but if the patient has successive attacks, some sympto ms may worsen
and persist.
 No cure exists for MS, but steroids may reduce the severity of attacks, and interferon beta (Rebif) and immunosuppressants
may min imize the symptoms.
Memory Tip – The sympto ms of
 Parkinson’s disease (Loss of dopamine producing cells in the brain)
Parkinson’s disease may be
 Sympto ms
remembered using the mnemonic
 Depression
TRAP:
 Difficulty swallowing or speaking
 Tremo rs
 Urinary problems or constipation
 Rig idity
 Sleep disruptions.
 Akinesia and Bradykinesia
 Treated with drugs that replace or stimulate production of dopamine
 Postural instability
 Myasthenia Gravis (Marked by muscle weakness often exacerbated by activity)
 Weakness often manifested by drooping eyelids or diplopia, weakness of the throat muscles with speech alteration s and
difficulty swallowing. Severe cases may depress the respiratory system or cause complete respiratory arrest.
 Admin istration of Edrophonium (Tensilon) improves symptoms.
 Controlled with medications such as such as pyridostigmine (Mestinon), barbitura tes, opiates, quinidine (Quinidex), quinine,
corticotropin (Acthar), cort icosteroids, aminoglycosides, antibiotics, and muscle relaxants.
 Gu illain-Barre [GBS] (acute inflammatory polyneuropathy that primarily affects the motor component of the peripheral nerves)
 Progression of illness
 Mild febrile illness 2 to 3 weeks prior to onset of GBS
 Neuropathy begins in lower ext remities and ascends in symmetrical pattern
 May affect respiratory muscles and cause respiratory insufficiency.
 Usually peaks in one week with motor function returning in descending fashion.
 Treat ment
 Largely supportive
 Onset may be arrested with plasmaphoresis or administration of IV immunoglobulins.
9 |P age
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
Practice Questions
Which of the follo wing factors would contribute to a suspicion of men ingitis?
a.
b.
c.
d.
The patient’s mother had men ingitis as a child
The patient is on oral antibiotics for periorb ital cellulitis
The patient was out camping in the woods the weekend preceding this ED visit
The patient had open heart surgery to repair a congenital heart defect at the age of five
Which of the follo wing blood pressure changes is associated with increased intracranial pressure?
a)
b)
c)
d)
Widening pulse pressure
Decrease in systolic pressure
Increase in diastolic pressure
Declining mean arterial pressure
A patient receiving intravenous phenytoin (Dilantin) experiences an intravenous extravasation. The emergency nurse should in itiate
which of the fo llowing interventions after discontinuing the infusion?
a)
b)
c)
d)
Apply dry heat to the area around the extravasation
Manually massage the area around the extravasation
Inject calciu m ch loride into the area around the extravasation
Encourage patient movement of the area around the extravasation
A patient presents to the ED with co mp laints of weakness to bilateral lo wer legs. Assessment reveals the upper arm reflexes are
dimin ished. A brief h istory indicates the patient suffered a viral illness approximat ely three weeks ago. The patient is diagnosed with
Gu illain-Barre syndrome. Which of the fo llo wing statements , made by the patient, indicates an understanding of teaching given to
this patient?
a.
b.
c.
d.
“I understand that my condition is palliative”
“I know that my condition will not affect my cognitive function.”
“I can expect to be on antiviral medicat ion for at least four weeks”.
“I will return to the hospital or follo w up with my physician if the weakness affects my hands.”
Answers: B, A, A, B
10 | P a g e
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
ENDOCRINE/ METAB OLIC EMERGENCIES
 Thyroid Emergencies
Mechanism
Clin ical
Manifestati
ons
Treat ment
_________________________
Elevated thyroid levels
_________________________
Decreased thyroid levels
•
•
•
•
•
•
•
•
•
Flushing, diaphoresis, hyperthermia
Anxiety, tremors, agitation, psychosis
Tachydysrhythmias, card iac failu re
Tachypnea, pulmonary edema
Hypertension
Hyperglycemia
Abdominal pain
Hypercalcemia
Metabolic acidosis
•
•
Treat precip itating cause
Reverse hyperthermia (acetaminophen, not
ASA)
 fluid and calories
Inhibit thyroid hormone synthesis (oral or
gastric tube)
• Propylthiouracil (PTU)
• Methimazole (Tapazole)
Slow thyroid hormone release (oral or slow
IV)
• Iodine (Lugol’s solution) one hour
later
Beta-blocker to decrease heart rate
Digo xin for heart failure
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Hypothermia without shivering
Fatigue, lethargy, impaired mentation, seizures, coma
Bradycardia
Hypoventilation
Hypotension
Hypoglycemia
Flu id retention
Dry skin
Respiratory or metabolic acidosis
Hyponatremia
Treat underlying causes (hypothermia, infections,
drug overdose)
Passive warming
Rehydration/sodium replacement
Intubation and mechanical ventilat ion for severe
hypoventilation.
Initiate IV thyroid hormone replacement
• Levothyroxine
• Thyroxine
 Hypoglycemia (blood sugar less than 50 mg/dL in adults and 40 mg/dL in infants - note that symptoms may appear in patients
with normally high blood sugars which have dropped precipitously at higher serum levels)
 Clin ical Manifestations
Mild hypoglycemia

Marked by:
Ep inephrine release
Clin ical
man ifestations




Cool, diaphoretic skin
Tachycardia
Palpitations
Shallo w respirations at a
normal rate
Dilated pupils
Moderate
hypoglycemia
Neuroglycemic
symptoms
 Altered LOC
 Slurred speech
 Headache
 Decreased
reaction times
Profound hypoglycemia
Inability of brain to extract o xygen




Disorientation
Seizures
Co ma
Permanent brain damage

Treat ment
 Conscious patient with gag reflex

 Admin ister 15 g of rapid-act ing carbohydrate and repeat if the patient does not improve within ten minutes
Unconscious patient


IV dext rose 25 – 50 mL

50% of adults

25% for children

10 – 12.5% for neonates
 IV o f D5 W
Patient with IV

Glucagon 1 mg IM (0.5 mg fo r children ages 3 – 5 and 0.25 mg for children < 3 years)

May not work for alcohol-induced hypoglycemia
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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Diabetic Ketoacidosis (DKA ) and Hyperosmolar Nonketotic Syndro me (HNS)
HNS
DKA
Dehydration
Profound
Less Profound
Acidosis
None
Co mmon
Diabetes
Type II
Type I
Blood Sugar
> 800 mg/d L
< 800 mg/d L
Ketones
Onset
BUN
Minimal
Days – weeks
Extremely elevated
Positive
Hours – days
Mild ly elevated

Clin ical manifestations and treatment
Effect
Clin ical manifestations
Treat ment considerations
Hyperglycemia



Metabolic acidosis
Diuresis causing
dehydration
Electrolyte
imbalances



Acetone odor to breath
Seru m g lucose greater 250
mg/d L
Polyphagia
Lethargy, weakness and fatigue
Weight loss













Kussmaul’s respirations
Seru m pH less than7.30
Fever
Polyuria and polydipsia
Tachycardia
Hypotension
Dry, hyperthermic, flushed skin
Dry mucus membranes
Poor skin turgor
 sodium
 chloride
 bicarbonate
 potassium
IV insulin (subcutaneous and intramuscular insulin is not
utilized because of erratic absorption in the face of
hypovolemia)
 Regular insulin (0.1 unit of regular insulin/kg of body weight
followed by 0.1 unit of regular insulin/kg/hour.)
 Maintain serum d rops at no more than 65 – 125 mg/d L/hour.
 When serum glucose drops below 250 mg/dL, switch to a
dextrose containing solution.
 Acidosis generally corrects itself as blood sugars are
corrected.
Normal saline boluses at one liter per hour for 1 – 2 hours
followed by 200 - 1000 mL/hour of 0.45% sodium ch loride.
(Ch ild ren should receive a bolus of 20 mL/ kg/hour for the first 1
-2 hours)
•
•
•
Measure electrolytes at the time of patient arrival and every
2 – 4 hours thereafter.
Seru m potassium will usually be elevated and will drop as
flu id resuscitation, insulin therapy, and acidosis correction
occur. Once serum potassium is < 5 mEq/ L, begin IV
potassium replacement to keep levels between 4 and 5
mEq/ L. (insulin therapy may need to be delayed if
potassium d rops below 3.3 mEq/L)
Replace phosphate and sodium as required.
12 | P a g e
Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
 Adrenal Emergencies


Insufficient adrenal hormones is called Addison’s disease. Severe adrenal insufficiency is called Addison’s crisis or adrenal
crisis.
Factors which can trigger an adrenal crisis
 Infections
 Hemorrhage
 Trau ma


Surgery
Burns

Pregnancy
Purpose
Adrenal
insufficiency
Al dosterone (mineralcorticoi d)
Reabsorbs water/sodium in the kidneys
• Increased urine and sodium loss
• Reflex sparing of potassium 
hyperkalemia and dysrhythmias
Cortisol (glucocorticoi d)
Increases serum glucose levels
• Inhibition of
glucogenesis 
hypoglycemia
Hydrocortisone (Solu-Cortef)
Dexamethasone (Decadron)
Primary
treatment
•
Other treat ment

Card iac monitor, IV insulin/dext rose or
kayexalate for hyperkalemia
• Oxygen, vasopressors and fluids (for
dehydration/hypovolemia)
Dextrose 50%
Cushing’s syndrome (elevated adrenal hormones secondary to prolonged exposure to elevated levels of endogenous or
exogenous glucocorticoids).
o Sympto ms:
 Cushingoid appearance


Moon facies

Buffalo hu mp back
 Fat above the clavicles
Increased risk of:

Hypertension

Obesity

Glucose intolerance

Osteoporosis and fractures

Impaired immune function

Impaired wound healing
Patients with Cushing’s syndrome are at risk
of developing adrenal crisis if they stop
exogenous steroids abruptly.
PRACTICE QUES TION
Which of the follo wing symptoms of hypoglycemia is considered an “early” man ifestat ion?
a)
b)
c)
d)
Headache
Tachycardia
Slurred speech
Slowed reaction time
Correct Answer: B
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Certified Emergency Nurse (CEN) Exam Review
Jeff Solheim
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