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Chapter 19
Neurology
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19-1
Objectives
19-2
Altered Mental Status
19-3
Altered Mental Status
• Change in a patient’s level of
awareness
• Also called an altered level of
consciousness (ALOC)
19-4
Common Causes of
Altered Mental Status
•
•
•
•
•
Alcohol, Abuse
Epilepsy
Insulin
Overdose
Uremia
• Trauma,
Temperature
• Infection
• Psychiatric
conditions
• Poisoning
• Shock, Stroke
19-5
Emergency Care
• Care focuses on airway, breathing,
circulation
• Stabilize spine if trauma is suspected
• Give oxygen
• Undo tight clothing
• Assess vital signs, oxygen saturation
• Maintain body temperature
• Comfort, calm, reassure patient
19-6
Seizures
19-7
Seizures
• Temporary change in
behavior or consciousness
• Caused by abnormal
electrical activity within 1 or
more groups of brain cells
• A symptom (not a disease)
of an underlying problem in
the central nervous system
19-8
Causes of Seizures
• Unknown cause
• Failure to take antiseizure medication
• Rapid rise in body
temperature
• Infection
• Hypoxia
• Head trauma
• Brain tumor
• Poisoning
• Hypoglycemia
• Seizure disorder
• Previous brain damage
• Electrolyte
disturbances
• Alcohol or drug
withdrawal
• Eclampsia
• Abnormal heart rhythm
• Genetic/hereditary
factors
• Stroke
19-9
Types of Seizures
• Generalized seizures
– Tonic-clonic
– Absence
• Partial seizures
– Simple partial
– Complex partial
19-10
Generalized Seizures
• Tonic-clonic seizures
– Very common
– Also called generalized motor seizures or
grand mal seizures
19-11
Generalized Seizures
• Tonic-clonic seizures
– Usually has four phases:
1.
2.
3.
4.
Aura
Tonic phase
Clonic phase
Postictal phase
19-12
Generalized Seizures
• Absence (petit mal) seizures
– Usually occur in children older than
5 years of age
– Can occur in adults
– Brief loss of consciousness (for 5 to 10
seconds) without a loss of muscle tone
19-13
Simple Partial Seizures
• Also called focal seizures or focal
motor seizures
• Usually last about 10 to 20 seconds
• Involve motor or sensory symptoms
with no change in mental status
19-14
Complex Partial Seizures
• Also called a temporal lobe seizure or
psychomotor seizure
• Patient’s consciousness,
responsiveness, or memory is impaired
• Often preceded by an aura
• Generally lasts less than 30 minutes
• May be associated with repeat
behaviors (automatisms)
19-15
Status Epilepticus
• Recurring seizures without an
intervening period of consciousness
• Medical emergency
• Can cause brain damage or death if it
is not treated
19-16
Patient Assessment
• Scene size-up
• Primary survey
• Secondary survey/physical exam
– Check for medical identification device
– Possible poisoning or toxic exposure?
– Signs of recent trauma?
• Show a caring attitude
19-17
Patient Assessment
History
• First seizure?
• History of seizures?
– Seizure medication?
– How often do the seizures usually occur?
– Does this seizure look like those the
patient has had before?
• Does the patient have a history of
stroke or diabetes?
• Does he have a history of heart
disease?
• Does the patient use or abuse alcohol
or drugs?
19-18
Patient Assessment
History
• What was the patient doing at the time of
the seizure?
– Did he hit his head or fall?
• Did the patient cry out or attract your
attention in any way?
• What did the seizure look like? When did
the seizure start? How long did it last?
• Did the seizure begin in 1 area of the body
and progress to others?
• Did the patient lose bowel or bladder
control?
19-19
Patient Assessment
History
• When the patient woke up, was there
any change in his speech?
• Was he able to move his arms and legs
normally?
• Did the patient exhibit any unusual
behavior before, during, or after the
seizure?
19-20
Emergency Care
• Treatment can be difficult
– Patient may be combative or confused
• Normal in the postictal phase
– Focus on the ABCs
19-21
Emergency Care
• Protect the patient’s
privacy
• Position the patient
• Protect the patient from
harm
• Do not insert anything
into the patient’s mouth
• Loosen tight clothing
• Remove eyeglasses
• Do not try to restrain
body movements
[Insert figure 19-3]
19-22
Emergency Care
•
•
•
•
Make sure the patient’s airway is open
Suction if necessary
Give oxygen
Comfort, calm, and reassure the patient and
family
• Watch closely for repeat seizures
• Relay patient information to appropriate
healthcare personnel
• Minimize patient exposure to bright lights
and loud noises
19-23
Stroke
19-24
Stroke
• Caused by the blockage or rupture of an
artery supplying the brain
• Also called a cerebrovascular accident or
brain attack
19-25
Types of Stroke
• Ischemic stroke
– Thrombotic
– Embolic
• Hemorrhagic stroke
– Subarachnoid hemorrhage
– Intracerebral hemorrhage
19-26
Ischemic Stroke
• Caused by a blood
clot that decreases
blood flow to the brain
• 80% of all strokes are
ischemic strokes
• Types of ischemic
strokes
[Insert figure 19-5]
– Thrombotic
– Embolic
19-27
Hemorrhagic Stroke
• Caused by bleeding into the brain
• Accounts for remaining 20% of all strokes
• Two forms
– Subarachnoid hemorrhage
– Intracerebral hemorrhage
19-28
Transient Ischemic Attack (TIA)
• “Mini-stroke”
• Temporary interruption of the blood supply
to the brain
• Signs and symptoms
– Resemble those of a stroke but are
temporary
– Last from a few minutes to several hours
19-29
Stroke Risk Factors
•
•
•
•
•
Hypertension
Cigarette smoking
Cardiovascular diseases
Diabetes mellitus
TIA
19-30
Stroke
Warning Signs
• Sudden weakness or numbness of the face, arm, or
leg on one side of the body
• Sudden facial drooping, inability to swallow, or
tongue deviation
• Sudden dimness or loss of vision, particularly in one
eye
• Loss of speech; trouble talking or understanding
speech
• Sudden, severe headache with no known cause
• Unexplained dizziness, unsteadiness, or sudden falls
• Confusion, agitation, combativeness, coma
• Seizures
• Inappropriate behavior, such as excessive laughing
or crying
19-31
Stroke Assessment Tools
• FAST assessment
– Face
– Arms
– Speech
– Time
19-32
Stroke Assessment Tools
• Give Me 5 for Stroke
1. Walk: Is their balance off?
2. Talk: Is their speech slurred or face
droopy?
3. Reach: Is one side weak or numb?
4. See: Is their vision all or partly lost?
5. Feel: Is their headache severe?
19-33
Stroke Assessment Tools
• Cincinnati Prehospital Stroke Scale
1.Facial droop
2.Arm drift
3.Speech
19-34
History
• Find out:
– Trauma to the head or neck?
– Taking any medications?
– When did patient’s symptoms begin?
– Sudden or gradual onset?
– Any seizure activity?
– Pertinent past medical history
19-35
Emergency Care
•
•
•
•
•
•
•
Spinal stabilization if trauma is suspected
Establish and maintain an open airway
Give oxygen
Position the patient and do not allow to walk
Protect paralyzed extremities from injury
Explain procedures to the patient
Assess vital signs, oxygen saturation, blood
glucose level
• Do not allow to eat or drink
• If appropriate, transport to nearest Stroke
Center
19-36
Syncope
19-37
Syncope
• A brief loss of responsiveness caused by a
temporary decrease in blood flow to the
brain
• Fainting
• Blackout
19-38
Syncope
Common Causes
•
•
•
•
•
•
•
•
•
Low blood sugar
Bearing down
Strenuous coughing
Breath holding or
hyperventilation
Sight of blood
Standing in place
too long
Bleeding,
dehydration
Some drugs
Sudden drop in BP
• Standing up
suddenly
• Head trauma
• Hot and humid
conditions
• Crowded places
• Eating a heavy meal
• Fasting
• Heart rate too
fast/too slow
• Stroke
• Witness to violence
19-39
Near Syncope
•
•
•
•
•
•
Dizziness
Anxiety
Lightheadedness
Pale skin
Sweating
Weakness
•
•
•
•
Nausea
Thready pulse
Low blood pressure
Partial or complete
loss of vision or
hearing
19-40
Patient Assessment
• Spinal stabilization if any possibility of
trauma
• Assess mental status, airway, breathing, and
circulation
• Focused history and physical examination if
responsive
• Rapid medical assessment if unresponsive
19-41
Emergency Care
• Establish and maintain an open airway
– Stabilize cervical spine if possibility of
trauma
•
•
•
•
Give oxygen
Position the patient supine
Remove or loosen tight clothing
Assess vital signs, oxygen saturation,
blood glucose level
• Maintain body temperature
• Comfort, calm, and reassure patient
and family
• Reassess
19-42
Headache
19-43
Sinus Headaches
• Sinuses
– Produce mucus and trap
bacteria
– Become swollen and inflamed
if passages are blocked
– Infection can result when
bacteria become entrapped in
the sinus tissues
• Headaches can be triggered by
the resulting pressure changes in
the sinuses.
19-44
Tension-type Headaches
• Most common type of headache
• Can occur at any age
– Onset during adolescence or young
adulthood is common
• Mild to moderate pain
• Feels like a tight band around the head
• Exact cause is unknown
19-45
Migraine Headaches
• Thought to be caused by changes in a
major pain pathway and imbalances in
brain chemicals
• May be accompanied by nausea,
vomiting, abdominal pain, or
sensitivity to light
• Can occur with or without an aura
• Family history of migraines common
19-46
Cluster Headaches
• Attacks of severe pain
primarily localized to the eye,
temple, forehead, or cheek
– Attacks occur in cyclical
patterns (clusters)
• Cause is uncertain
• Typically begins quickly,
usually without warning
19-47
Medication-induced Headaches
• Also called rebound headaches
• Can result from overuse of medications or
substances
19-48
Organic Headaches
• Organic headaches are the result of an
abnormality in the brain or skull.
• Possible causes
– Infection
– Cerebral hemorrhage
– Benign or malignant brain tumor
– Cerebral aneurysm
19-49
Patient Assessment
• Spinal stabilization if any possibility of
trauma
• Assess mental status, airway, breathing, and
circulation
• Focused history and physical examination if
responsive
• Rapid medical assessment if unresponsive
19-50
Possible Signs/Symptoms
• Sinus headaches
– Dull pressure-like pain in one specific area
of the face or head, such as behind the
eyes
– Facial tenderness to touch
– Pain may worsen with sudden movement
of the head or bending forward
– Yellow-green or blood-tinged nasal
discharge
– Possible fever
19-51
Possible Signs/Symptoms
• Mild to moderate pain that feels like a tight
band around the head
• Headache occurs primarily in the forehead,
temples, back of the head and/or neck
• Tightness in the neck, as if the head and
neck were in a cast
19-52
Possible Signs/Symptoms
• Cluster headaches
– Sudden onset of excruciating pain
described as sharp, penetrating, boring, or
burning; pain is so intense that most
patients cannot sit still
– Tearing of the eye, swelling around the
eye, possible drooping eyelid, and a stuffy
or runny nose on the affected side of the
face
– Flushing on the affected side of the face
– Sweaty, pale skin
19-53
Possible Signs/Symptoms
• Medication-induced headaches
– Typically occur daily
– Start of the headache is generally the
worst, as the medication wears off
– Nausea
– Anxiety, restlessness, irritability, difficulty
concentrating
– Depression
– Trouble sleeping
19-54
Possible Signs/Symptoms
• Organic headaches
– Sudden sharp, intense, or severe
headache
– Sudden lack of balance or falling
– Confusion
– Inappropriate behavior
– Seizures
– Difficulty speaking
19-55
Emergency Care
• Establish and maintain an open airway
– Stabilize cervical spine if possibility of
trauma
• Give oxygen
• Position of comfort
• Assess vital signs, oxygen saturation,
blood glucose level
• Comfort, calm, and reassure patient
and family
19-56
Questions?
19-57