Download Nervous System - faculty at Chemeketa

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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
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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
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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
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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 – History
Be organized and systematic!
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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
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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 Coma
Structural
• 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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DDX
Structural lesions
Commonly asymmetrical neurological signs
Acute onset
Unresponsive or asymmetrical pupillary
responses
Toxic-metabolic coma
Neurological findings symmetrical
Coma slow in onset
Preserved 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
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before rupture
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
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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
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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 Documentation
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S:\HealthOccupations\EMS\EMT Paramedic\Neuro\Nervous System emergencies.ppt
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