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Chapter 18
Neurologic
Emergencies
National EMS Education
Standard Competencies
Medicine
Integrates assessment findings with principles
of epidemiology and pathophysiology to
formulate a field impression and implement a
comprehensive treatment/disposition plan for
a patient with a medical complaints.
National EMS Education
Standard Competencies
Neurology
• Anatomy, presentations, and management
of
− Decreased level of responsiveness
• Anatomy, physiology pathophysiology,
assessment and management of
−
−
−
−
Stroke/transient ischemic attack
Seizure
Status epilepticus
Headache
National EMS Education
Standard Competencies
Neurology (cont’d)
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
− Stroke/intracranial hemorrhage/transient ischemic
attack
− Seizure
− Status epilepticus
− Headache
− Dementia
− Neoplasms
− Demyelinating disorders
National EMS Education
Standard Competencies
Neurology (cont’d)
• Anatomy, physiology, epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of
(cont’d)
−
−
−
−
−
−
−
Parkinson’s disease
Cranial nerve disorders
Movement disorders
Neurologic inflammation/infection
Spinal cord compression
Hydrocephalus
Wernicke encephalopathy
Introduction
• Three of the top 15 causes of death in 2007
were neurologic in nature.
− Prevalence: number of people in a given
population with a particular disease
− Incidence: number of people diagnosed with a
particular disorder in a one-year period
Introduction
Introduction
• Patients may be in danger.
− Eyelids do not blink.
− Larynx does not cause gagging and coughing.
− Body does not seek a position of comfort.
− Tongue goes slack.
− Airway is at risk.
Structure of the Nervous
System
• Two major structures
− Brain
− Spinal cord
• Responsible for fundamental functions
Structure of the Nervous
System
• Major structure divided into two categories:
− Central nervous system
• Thought
• Perception
• Feeling
• Autonomic body functions
− Peripheral nervous system
• Communication between the brain and the body
© Jones & Bartlett Learning
Structure of the Nervous
System
The Brain
• Lobes
− Occipital lobe: scans through images
− Temporal lobe: attaches image to name
− Frontal lobe: controls voluntary motion
• Efferent nerves: convey commands to the body
• Afferent nerves: send signals of discomfort
− Parietal lobe: perceives touch and pain
The Brain
© Jones & Bartlett Learning
The Brain
• Diencephalon and brainstem
− Diencephalon: filters out unneeded information
− Brainstem
• Midbrain: regulates level of consciousness
• Pons: controls respiratory pace and depth
• Medulla oblongata: controls blood pressure and
pulse rate
The Brain
The Brain
• Hypothalamus and pituitary gland
− Limbic system: generates rage and anger
− Hypothalamus: Controls pleasure, thirst, hunger
• Communicates to the pituitary gland to send
messages to the adrenal glands
• Adrenal glands release epinephrine and
norepinephrine.
The Brain
• Cerebellum
− Located in posterior, inferior area of the skull
− Manages complex motor activity
− Learned behaviors are transferred from the
frontal lobe.
Neurons and Impulse
Transmission
• A neuron contains:
− Cell body
− Axon: projection extending toward another cell
− Axon terminal: where neurotransmitters are
made
− Dendrites: Carry signals toward the nucleus
Neurons and Impulse
Transmission
• Synapses: slight gap between each cell
• Neurotransmitters: connects synapse to
next cell
− Relay electrically conducted signals
Neurons and Impulse
Transmission
• Axons
− Many are coated with myelin.
• Insulating substance that allows the cell to transmit
its signal consistently
• Increases the speed of conduction
Neurons and Impulse
Transmission
Patient Assessment
• The brain is sensitive to change in
temperatures and levels of oxygen and
glucose.
• The brain is resilient to internal
environmental changes.
Scene Size-up
• Standard precautions protect you from
harmful organisms or environments.
− Gloves are a standard approach.
− Based on the procedure you are conducting and
the likelihood of contamination
Scene Size-up
• The patient’s location may place you in a
dangerous situation.
− Assessment begins at dispatch.
− Examine the scene as you approach.
• Ensure that you have a way to remove yourself.
Scene Size-up
• Gather basic information about the call.
− Determine if you need additional resources or
equipment.
− Determine number of patients.
− Ensure that you have the correct PPE.
Primary Assessment
• Form a general
impression.
−
−
−
−
−
−
Where is the patient?
In distress or pain?
Position?
Inside or outside?
Obvious injuries?
Environment?
− Drug paraphernalia?
− Living conditions?
− Conscious or
unconscious?
− Stable or unstable?
Primary Assessment
• Form a general impression (cont’d).
− Information can be used to:
• Identify social service needs.
• Help direct injury prevention education.
• Assess patient needs upon discharge.
• Determine the effects of past interventions.
Primary Assessment
• Airway and breathing
− Listen to the quality of the patient’s voice.
− Nerves responsible for airway control allow for:
• Swallowing
• Controlling the tongue
• Slightly contracted muscles in hypopharynx
Primary Assessment
• Airway and breathing (cont’d)
− If patient is unresponsive, assess the airway.
− Stridor may indicate partial obstruction.
− Trismus may indicate:
• A seizure in progress
• Severe head injury
• Cerebral hypoxia
Primary Assessment
• Airway and breathing (cont’d)
− If you suspect an obstruction:
• Evaluate the airway.
• If there is no response, examine for obstructions.
• Use Magill forceps to remove any objects.
• Be prepared to perform endotracheal intubation.
• Ensure oxygen saturation level of 94%.
Primary Assessment
• Airway and breathing (cont’d)
− Provide routine hyperventilation only to those
patients with both:
• Documented unconsciousness
• Signs of increased intracranial pressure (ICP).
Primary Assessment
Primary Assessment
• Circulation
− Evaluate peripheral and central pulse patterns.
− Evaluate skin.
Primary Assessment
• Circulation (cont’d)
− Evidence of ICP:
• Cushing reflex
• Decorticate posturing
• Decerebrate posturing
• Biot’s respirations
• Apneustic respirations
• Cheyne-Stokes respirations
• Anisocoria
Primary Assessment
• Circulation (cont’d)
− Establish vascular access.
− Consider drawing blood samples.
− Check blood pressure and pulse rate.
• Target systolic pressure: 110 to 120 mm Hg
− Perform continuous heart monitoring.
Primary Assessment
• Circulation
(cont’d)
− As the ICP rises:
• Blood flow to the
brain diminishes.
• Heart increases
contraction force.
• Systolic pressure
rises.
• Ability to send
signals is
damaged.
• Diastole falls.
• Ability to control
respiratory and
pulse rates is
damaged.
Primary Assessment
• Transport decision
− Consider how to transport:
• Complete a rapid secondary assessment.
• Complete a secondary assessment and evaluate
only the area(s) of patient complaint(s).
Primary Assessment
• Transport decision (cont’d)
− A rapid exam should be performed with:
• An abnormal assessment
• A significant MOI/NOI
• Any patient you suspect may have a major problem
− A secondary assessment is appropriate if the
patient is stable.
History Taking
• If stable, obtain history.
− Ask what happened.
− Look for signs and symptoms.
− Evaluate the patient’s speech.
History Taking
• If patient has had a seizure:
− Look for obvious explanations.
• For headache, determine:
− The patient’s level of stress
− The likelihood of infection
− History of headaches
History Taking
• If responsive, obtain a SAMPLE history.
− If first seizure:
• Suspect a grave condition.
• Determine whether the patient takes medications
that lower the blood glucose level.
• Inquire about drug use and exposure to toxins.
Secondary Assessment
• Head
− DCAP-BTLS?
• Neck
−
−
−
−
−
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DCAP-BTLS?
Symmetry?
Masses?
Is the trachea midline?
JVD?
Vertebrae aligned?
• Chest
−
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−
−
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DCAP-BTLS?
Symmetry?
Equal rise and fall?
Evaluate ECG
Respiratory
distress/effort?
− Lung sounds?
− Determine pulse
oximeter reading.
Secondary Assessment
• Abdomen
−
−
−
−
DCAP-BTLS?
Masses?
Pulsations?
Nausea/vomiting?
• Pelvis
− DCAP-BTLS?
− Stability?
− Incontinence?
• Extremities
− DCAP-BTLS?
− Examine pulses,
motor function,
sensation
− Edema?
− Venipuncture marks?
• Back
− DCAP-BTLS?
− Ensure curves are in
correct place.
Secondary Assessment
− Ptosis: the
dropping sagging,
or prolapse of a
part of the body
© Dr. P. Marazzi/Photo Researchers, Inc.
• Note the symmetry
of the face.
Secondary Assessment
• Level of consciousness
− There can be many variations.
Secondary Assessment
• AVPU
− A: Awake and alert
− V: Responds to verbal
stimuli
− P: Responds to painful
stimuli
Courtesy of Chuck Sowerbrower,
MED, NREMT-P
• Fingernail pressure
• Pressure to the
supraorbital foramen
Secondary Assessment
• AVPU
− P: Responds to
painful stimuli
(cont’d)
• Decorticate
posturing
(abnormal flexion)
• Decerebrate
posturing
(abnormal
extension)
− U: Unresponsive
Secondary Assessment
• Glasgow Coma Scale (GCS)
− Scores are added together to define brain
function
Secondary Assessment
• Glasgow Coma
Scale (cont’d)
− Determines:
• How to proceed
• Care to be given
• Where the patient
should be
transported
Secondary Assessment
• Orientation
− Tests mental status.
− Evaluates four areas:
• Person
• Place
• Time
• Event
− Confusion may
indicate:
• Low blood glucose
• Decreased oxygen
• Overdose
• Decreased blood
pressure
Secondary Assessment
• Common reality
− Hallucinations: feelings of sound, sight, touch,
and taste that are entirely within patient’s mind
− Delusions: Thoughts or perceived abilities are
not based in a common reality.
Secondary Assessment
• Common reality (cont’d)
− Psychosis: inability to determine what is real
and what is inside patient’s mind
• Ensure your safety.
− Medication may be needed to help manage.
Secondary Assessment
• Other changes
− Ask patient how he or she feels.
− Ask patient how easy it is for him or her think.
Secondary Assessment
• Corneal reflex
− Determines intact cough and gag reflexes.
− Tap between the patient’s eyes.
• Patients with reflexes will blink reflexively.
• If the patient does not blink or twitch, assume that
the patient does not have an intact cough or gag
reflex.
Secondary Assessment
• Cranial nerve functioning
− Abnormal functioning may occur with stroke,
trigeminal neuralgia, or myasthenia gravis.
Secondary Assessment
Secondary Assessment
• Speech
− Agnosia: inability to name common objects
− Apraxia: inability to know how to use objects
− To test for these signs:
• Show patient an object and ask for the name.
• If patient responds correctly, ask how to use the
object.
Secondary Assessment
• Speech (cont’d)
− Receptive aphasia: inability to understand
speech with ability to speak clearly
− Expressive aphasia: inability to speak clearly
with ability to understand speech
− Global aphasia: inability to follow commands or
answer questions
Secondary Assessment
• Hemiparesis and hemiplegia
− Hemiparesis: weakness of one side of the body
− Hemiplegia: paralysis of one side of the body
− Decussation: the crossing of nerves as they
leave the cerebral cortex
Secondary Assessment
• Hemiparesis and
hemiplegia
(cont’d)
− Examine the
function of the
cerebellum.
• Have patient close
eyes and hold out
arms.
• If stroke, one arm
may drift away
from the other.
© Jones & Bartlett Learning. Courtesy of MIEMSS.
Secondary Assessment
• Gait and posture
− Gait: walking patterns
− Ataxia: alteration of ability to perform
coordinated motions
− Assess by asking patient to walk several steps.
• Posture may become rigid.
Secondary Assessment
• Bizarre movement
− Myoclonus: rapid, jerky muscle contraction that
occurs involuntarily
− Dystonia: a part of the body contracts and
remains contracted
Secondary Assessment
• Alterations in smooth motion
− Rigidity: stiffness of motion
− Tremors: fine, oscillating movement
• Rest tremor: occurs when at rest and not moving
• Intention tremor: occurs when asked to grab object
• Postural tremor: occurs when a body part is
required to maintain a particular position
Secondary Assessment
• Alterations in smooth motion (cont’d)
− Seizure: larger, less focused movement
• Tonic activity: rigid, contracted body posture
• Clonic activity: rhythmic contraction and relaxation
of muscle groups
Secondary Assessment
• Sensation
− Paresthesia: sensation of numbness or tingling
− Anesthesia: no feeling within a body part
• Blood glucose level
− Normal reading is 60 to 120 mg/dL.
− Below 10 mg/dL is usually fatal.
Secondary Assessment
• Vital signs
− Document:
• Pulse rate, rhythm, and quality
• Respiratory rate, rhythm, and quality
• Blood pressure
• Skin temperature, color, and condition
• Pupil size and reactivity
Secondary Assessment
• Vital signs (cont’d)
− Ensure maintenance of a systolic blood
pressure of at least 110 to 120 mm Hg.
− Ensure adequate respiratory rate and pattern.
− Ensure effective pulse rate and rhythm.
Secondary Assessment
• Vital signs (cont’d)
− If hypothermia or hyperthermia is suspected,
use a thermometer to establish temperature.
• Avoid the axillary method.
• If unable, gather information about the NOI.
• Do not actively rewarm or cool patients.
Reassessment
• Administration of dextrose 50%
− Dose: 25 g or one full syringe
− Effects begin in 30 seconds to 2 minutes.
• If there is no effect, administer a second dose.
− Can substitute dextrose 25% (two syringes)
Reassessment
• Administration of dextrose 50% (cont’d)
− If extremely malnourished, first give thiamine
− If IV access cannot be obtained, administer
0.5 to 1 mg of glucagon.
Reassessment
• Administration of dextrose 50% (cont’d)
− If unresponsive or decreased LOC:
• Administer 12.5 g (1/2 syringe) of dextrose 50%.
• Reassess.
• Proceed with additional dextrose cautiously.
Reassessment
• Airway management
− Provide oxygen, ventilation, and protection.
− Ensure that pulse oximeter reading is 95% or
better.
− Provide oxygen and ventilatory assistance as
needed.
Reassessment
• Airway management (cont’d)
− If trismus is noted:
• If ventilation is poor and patient is breathing on
his/her own, attempt a nasotracheal airway.
• If unsuccessful, consider a paralytic agent.
• If paralytics are unavailable, transtracheal airway
management is the only option.
Reassessment
• Administration of naloxone
− Used for unresponsive/unknown patients or
those with suspected narcotic overdose
− Initial dose is 0.4 to 2 mg IVP.
− Can result in rapid change in LOC
Reassessment
• Administration of naloxone (cont’d)
− Ensure airway and adequate BLS ventilation.
• Do not immediately intubate.
• Establish an IV line and administer.
• After administering, intubation may be needed.
Reassessment
• Rectal administration of diazepam
− Dose is 0.2 mg/kg.
− Take standard precautions.
− Draw up dose, then remove and dispose of
needle.
Reassessment
• Rectal administration of diazepam (cont’d)
− Attach an angiocatheter to the end of the
syringe; remove and dispose of the needle.
− Insert the plastic catheter into the rectum.
− Inject the medication and remove the catheter.
− Hold the buttocks together for 5 minutes.
Reassessment
• Communication and documentation
− Notify the receiving facility of:
• Time the patient was last seen healthy
• Findings of neurologic examination
• Anticipated time of arrival at the hospital
Reassessment
• Communication and documentation
(cont’d)
− Document:
• Time of the onset
• Findings from stroke scale and GCS score
• Airway management and interventions performed
• Any change in patient during transport
• Reason for choice of hospital
Reassessment
• Communication and documentation
(cont’d)
− For patients who have had a seizure, document:
• Description of seizure activity
• Bystanders’ comments
• Onset and duration
• Evidence of trauma
• Interventions performed
• History of seizures
Reassessment
• Communication and documentation
(cont’d)
− When documenting interventions include:
• Time of each intervention
• How the patient responded
• What the findings showed
Common Neurologic
Emergencies
• Most diseases or conditions are caused by
more than one factor.
− Disease susceptibility is often related to:
• Development of embryo/fetus
• Effectiveness of body’s defense and repair
functions
• Exposure to pathogen, toxin, or other damaging
factor
Stroke
• Blood supply to areas of the brain is
interrupted, causing ischemia
• Goal of treatment: early recognition and
rapid, appropriate intervention
Pathophysiology of Stroke
• Neurologic conditions can have a vascular
origin.
− Typically result of emboli or aneurysms
Pathophysiology of Stroke
• Aneurysm development process:
− Small tears occur within the arterial wall.
− Blood enters between the layers of the artery.
− Pressure builds up, and the tear increases.
− If damage is severe, the artery can leak or fail.
Pathophysiology of Stroke
• Ischemic stroke
− A blood vessel becomes blocked, causing
tissue beyond it to become ischemic.
− The severity is dictated by:
• Artery involved
• Portion of the brain being denied oxygen
Pathophysiology of Stroke
• Hemorrhagic stroke
− Tend to get worse over time
• Bleeding causes increased ICP and brainstem
herniation.
− Primary symptom: “worst headache of my life”
Pathophysiology of Stroke
• When ICP climbs and remains high:
− The brain may become ischemic because of a
lack of blood supply.
• Cerebral perfusion pressure (CPP) begins to fall.
− CPP = MAP (mean arterial pressure) – ICP
• MAP: 80 to 90 mm Hg
Pathophysiology of Stroke
Pathophysiology of Stroke
• When ICP climbs and remains high
(cont’d):
− Herniation may occur.
• Shift or displacement of intracranial contents
• Brainstem will eventually become compressed.
• Patient will lose control of his/her functions.
Assessment of Stroke
• Language effects
−
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Slurred speech
Aphasia
Agnosia
Apraxia
• Movement effects
−
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Hemiparesis
Hemiplegia
Arm drifting
Facial droop
Tongue deviation
Swallowing difficulties
Ptosis
Ataxia
Assessment of Stroke
• Sensory effects
− Headache
(hemorrhagic)
− Sudden blindness
− Sudden unilateral
paresthesia
• Cognitive effects
−
−
−
−
Decreased LOC
Difficulty thinking
Seizures
Coma
• Cardiac effects
− Hypertension
Management of Stroke
• Administer fluids as needed.
• Elevate the patient’s head 30°.
• Ensure airway is clear.
• Watch for seizures.
• Monitor blood pressure closely.
Management of Stroke
• High oxygen level constricts arteries.
• Lower level of carbon dioxide lowers ICP.
− Ventilation decreases CO2 and increases O2.
• Provide ventilatory support at 16 to 20 breaths/min.
• Maintain PET CO2 in high 20s to low 30s mm Hg.
Management of Stroke
Reproduced with permission, 2010 American Heart Association Guidelines for Cardiopulmonary
Resuscitation and Emergency Cardiovascular Care. ©2010, American Heart Association.
Management of Stroke
• EMS providers need to be involved in
educating the community about strokes.
• All levels should recognize stroke.
− Use a standard stroke assessment tool.
• Cincinnati Prehospital Stroke Scale
• Los Angeles Prehospital Stroke Screen
Management of Stroke
Management of Stroke
• Standard stroke care includes:
− Titrating oxygen therapy to the patient’s need
• Maintain an SPO2 reading of 95% or greater.
• Use other techniques to assess need for oxygen.
• Complete a fibrinolytic checklist.
Management of Stroke
Management of Stroke
• Transport decisions
− Transport to stroke centers.
− If you suspect hemorrhagic stroke, consider a
facility that can perform neurosurgery.
• Call ahead to ensure rapid evaluation.
Transient Ischemic Attacks
• Pathophysiology
− Episodes of cerebral ischemia without
permanent damage
− Presentations will resolve within 24 hours.
− May be a sign of a vascular problem
Transient Ischemic Attacks
• Assessment
− Same as assessment for stroke
• Management
− Follow the stroke management guidelines.
− Encourage the patient to be transported and to
talk with his/her physician.
Coma
• Pathophysiology
− Many reasons for a decreased LOC.
Coma
• Pathophysiology (cont’d)
− History of present illness is vital to determine
the underlying cause
• Determine when the patient was last seen normal.
• Evaluate the speed of onset.
Coma
• Assessment
− Cognitive effects
• Decreasing LOC
• Confusion
• Hallucinations
• Delusions
• Psychosis
• Difficulty thinking
• Sleepiness
− Speech effects
• Slurred speech
• Agnosia
• Apraxia
• Aphasia
− Movement effects
• Ataxia
• Seizures
• Posturing
− CNS effects
• Total
unresponsiveness
Coma
• Management
− Support vital
functions.
− Gather information
about the cause.
• Administer naloxone
if you suspect
narcotic overdose.
− Patients may need:
• Urine and blood
analysis
• Radiography
• Computed
tomography
• Magnetic resonance
imaging
Seizures
• Pathophysiology
− Sudden erratic firing of neurons
− Signs and symptoms include:
• Muscle spasms
• Increased secretions
• Cyanosis
Seizures
• Pathophysiology (cont’d)
− If a seizure continues for a long time:
• Cerebral glucose and oxygen supplies can be
depleted.
• There can be serious, long-term effects, including
death.
Seizures
• Try to determine
the cause of the
seizure.
− Medication
compliance
− Fever
− Low blood glucose
level in diabetics
Seizures
• Assessment of generalized seizures
− Tonic/clonic steps:
• Aura
• Loss of consciousness
• Tonic phase
• Hypertonic phase
• Clonic phase
• Postseizure
• Postictal
Seizures
• Assessment of generalized seizures
(cont’d)
− Absence seizures (petit mal seizures)
• Typical patient: child
• Patient stops and freezes mid-action.
• Usually no longer than several seconds
Seizures
• Assessment of generalized seizures
− Pseudoseizures
• Cause is of psychiatric origin
• Triggered by emotional event, stress, lights, or pain
• Occurs with witnesses
• Motion is relatively organized.
Seizures
• Assessment of partial seizures
− Only a limited part of the brain is involved.
− Simple partial seizures involve either:
• Movement of one part of the body (frontal lobe)
• Sensations in one part of the body (parietal lobe)
Seizures
• Assessment of
partial seizures
(cont’d)
− Complex partial
seizures involve
changes in LOC.
− Patients typically
do not become
unresponsive.
Seizures
• Management
− Determine whether trauma is a concern.
− Do not restrain the patient.
− Remain calm.
− Prevent the patient from becoming injured.
− Do not place anything in the patient’s mouth.
Seizures
• Management (cont’d)
− Correct hypoglycemia as needed.
− Ventilatory assistance may be necessary.
− Provide emotional support.
− All patients should be transported.
Seizures
• Management (cont’d)
− If you are concerned of seizure during transport:
• Be prepared to administer diazepam or lorazepam.
• Pad cot and rails.
• Ensure cot straps are not too tight.
Status Epilepticus
• Pathophysiology
− Seizure that lasts longer than 4 to 5 minutes or
consecutive seizures
• May result in neurons being damaged or killed
− Goal: stop seizure and ensure adequate ABCs.
Status Epilepticus
• Assessment
− Same as for a seizure
• Management
− Administer a benzodiazepine.
− Be prepared to control airway and ventilation.
− Paralytics may be needed.
Syncope
• Pathophysiology
− Sudden and
temporary loss of
consciousness with
loss of postural
tone
− A short interruption
in blood flow
causes loss of
consciousness.
Syncope
• Assessment
− Patient is often in a
standing position.
− Vasovagal
syncope typical in
younger adults
− Cardiac
dysrhythmia is a
typical cause in
older adults.
Syncope
• Assessment (cont’d)
− Prodromal signs and symptoms may include:
• Dizziness
• Chest pain
• Loss of vision
− Incontinence is possible.
Syncope
• Management
− Determine if trauma has occurred.
− Focus on blood pressure and cardiac causes.
− Evaluate blood glucose and oxygen saturation.
− Obtain orthostatic vital signs.
− Provide emotional support and transport.
Headache
• Pathophysiology and assessment of muscle
tension headaches
− Stress causes residual muscle contractions.
− Pain is generally felt on both sides of the head.
− Usually a dull ache or a squeezing pain
Headache
• Pathophysiology and assessment of
migraine headaches
− Caused by changes in the size of blood vessels
at the base of the brain
− Patient may report an aura.
− Pain is generally unilateral and focused.
Headache
• Pathophysiology and assessment of cluster
headaches
− Begins as minor pain around one eye
• Intensifies and spreads to one side of the face.
− Occur in groups and last 30–45 minutes each
Headache
• Pathophysiology and assessment of sinus
headaches
− Inflammation/infection within sinus cavities
− Pain is located in superior portions of the face.
− May be accompanied by postnasal drip, sore
throat, and nasal discharge
Headache
• Management
− Treat for stroke
if other signs
are present.
− Ask what
medications
patient has
taken.
Headache
• Management
(cont’d)
− Medication for
pain management:
• Ketorolac
tromethamine
• Meperidine
• Morphine
− For nausea and
vomiting, consider:
• Promethazine
• Ondansetron
Dementia
• Pathophysiology
− Chronic deterioration of:
• Memory
• Personality
• Language skills
• Perception, reasoning, or judgment
− Changes occur over weeks to years.
Dementia
• Pathophysiology (cont’d)
− Causes vary.
• Wernicke encephalopathy is caused by vitamin B1
deficiency
• Alzheimer’s disease is a progressive condition in
which neurons die.
Dementia
• Assessment
− Obvious that it is not simple memory loss
− Patients may become aggressive or violent.
− Confusion is the hallmark sign.
Dementia
Dementia
• Management
− Ensure that no reversible cause is present.
− Check:
• Blood glucose level
• Oxygen level
• Blood chemistry
Dementia
• Management (cont’d)
− Wernicke encephalopathy
• Administer thiamine before glucose is given.
• Perform ECG monitoring.
• Obtain blood chemistries.
Neoplasms
• Pathophysiology
− Growths within the body that are caused by
errors that occur during cellular reproduction
− Mitosis: cellular reproduction
© Jones & Bartlett Learning
• A parent cell divides into two daughter cells.
Neoplasms
• Pathophysiology (cont’d)
− Daughter cells are copies of the parent cell.
• Ensures continued functioning of vital structures
• If a severe error occurs, the cell will have too much
damaged DNA to survive.
• If a subtle error occurs, the cell may survive.
Neoplasms
• Pathophysiology
(cont’d)
− Benign neoplasms
• Not cancerous
− Malignant neoplasms
• Take over blood
supplies.
• Move to other sites.
− Primary neoplasms
• Cancers that arise
within the nervous
system
− Metastatic neoplasms
• Cancers that spread
to the nervous
system
Neoplasms
• Assessment
− Signs and symptoms
of brain tumors:
− Signs and symptoms
of spinal tumors:
• Headache
• Back pain
• Vomiting
• Seizures
• Weakness
• Loss of limb
sensation
• Stroke-like
symptoms
• Incontinence
Neoplasms
• Management
− Watch for status epilepticus.
− Administer diazepam if needed.
− Protect limbs from injury.
Multiple Sclerosis
• Pathophysiology
− Autoimmune condition in which the body attacks
the myelin of the brain and spinal cord
• Results in demyelination
• The body begins to attack its own cells.
Multiple Sclerosis
• Assessment
− Follows a pattern of attacks and remissions
− Common complaints of initial attack include:
• Double vision
• Blurred vision
• Nystagmus
Multiple Sclerosis
• Assessment (cont’d)
− Other signs may include:
• Muscle weakness
• Speech disturbances
• Vertigo
• Euphoria
• Electrical sensations
Multiple Sclerosis
• Management
− Prehospital management is supportive.
− Be prepared for trauma related to a fall.
− In-hospital treatment is aimed at controlling the
symptoms.
Guillain-Barré Syndrome
• Pathophysiology
− Disease in which the immune system attacks
portions of the nervous system
− May report previous respiratory or GI infection
− Some patients recover completely; others
require assistance for the rest of their lives.
Guillain-Barré Syndrome
• Assessment
− Begins as weakness in the legs
• Moves up the legs and affects the thorax and arms.
• Can lead to paralysis
− Patients are prone to severe swings in pulse
rate and blood pressure.
Guillain-Barré Syndrome
• Management
− Assess ability to protect the airway.
− Monitor closely with ECG.
− Repeat vital signs.
− Obtain continuous end tidal CO2 readings.
− Be prepared to administer IV fluids.
− Provide comfort.
Amyotrophic Lateral Sclerosis
• Strikes the voluntary motor neurons
• Cause is unclear
• Most common in middle-aged men
Amyotrophic Lateral Sclerosis
• Assessment
− Initially subtle and progresses without notice
− Signs and symptoms include:
• Fatigue
• General weakness of muscle groups
• Difficulty doing routine activities
Amyotrophic Lateral Sclerosis
• Management
− Monitor the airway.
− Transportation may become complicated.
− In-hospital care includes:
• Physical therapy
• Medication to mitigate certain symptoms
Parkinson’s Disease
• Pathophysiology
− Neurologic condition in which past injuries to the
brain can have an influence
• The substantia nigra is damaged.
Parkinson’s Disease
• Assessment
− Onset is gradual (months to years)
− Classic presentation involves:
• Tremor
• Postural instability
• Rigidity
• Bradykinesia
Parkinson’s Disease
• Management
− Prehospital management is supportive.
− Treat any injuries.
− In-hospital treatment includes levodopa.
Cranial Nerve Disorders
• Pathophysiology
− May mimic other conditions
Cranial Nerve Disorders
• Assessment
− Test for vertigo.
• Have patient lie supine.
• Move the head rapidly from side to side.
• Look at patient’s eyes.
− If patient has vertigo, nystagmus will be seen.
Cranial Nerve Disorders
• Management
− For nausea and vomiting, patient may need:
• Promethazine
• Ondansetron
Dystonia
• Pathophysiology
− Severe, muscle
spasms that cause
bizarre contortions,
repetitive motions,
or postures
− Occur for unknown
reason
© Dr. P. Marazzi/Photo Researchers, Inc.
Dystonia
• Assessment
− Spasms are involuntary and often painful
• Management
− Focus on ruling out other problems.
− Pain management may be appropriate.
− Be calm and reassuring.
CNS Infections/Inflammation
• Pathophysiology
− Encephalitis: inflammation of the brain
− Meningitis: inflammation of the meninges
− Damage is caused by:
• Body’s reaction to the infection, or
• Activities of the attacking organisms
CNS Infections/Inflammation
• Pathophysiology (cont’d)
− If temperature becomes too high, a person may:
• Hallucinate
• Become delusional
• Lose consciousness
• Have a febrile seizure
CNS Infections/Inflammation
• Pathophysiology (cont’d)
− Proteins that damage cells
• Endotoxins: released by gram-negative bacteria
• Exotoxins: secreted by some bacteria or fungi
− Virus attacks the axons.
− Both illnesses
begin with flulike
symptoms.
− Meningitis may
elicit:
• Kernig’s sign
• Brudzinski’s sign
© Jones & Bartlett Learning
• Assessment
© Jones & Bartlett Learning
CNS Infections/Inflammation
CNS Infections/Inflammation
• Management
− If meningitis is suspected:
• Place a mask over the patient’s mouth.
• Wear a mask if the patient is coughing.
− Be prepared for seizures.
CNS Infections/Inflammation
• Management (cont’d)
− Paramedic may need antibiotic treatment.
− Hospital treatment includes:
• Decreasing swelling in the brain and spinal cord
• Fighting the infection
• Supporting the patient’s vital signs
Abscesses
• Pathophysiology
− Caused by an infectious agent within the brain
or spinal cord
− Often preceded by an infection of the sinuses,
throat, gums, or ear
Abscesses
• Assessment
− Signs and symptoms may include:
• Low- or high-grade fever
• Generalized or focal seizures
• Nausea and vomiting
• Focal motor or sensory impairments
Abscesses
• Management
− Pay attention for increased ICP.
− Take seizure precautions.
− Evaluate temperature.
Poliomyelitis and Postpolio
Syndrome
• Pathophysiology
− Viral infection
transmitted by
fecal-oral route
− Most patients do
not become ill.
• Assessment
− Severe cases:
• Sore throat
• Nausea, vomiting,
diarrhea
• Stiff neck
• Muscle weakness/
paralysis
Poliomyelitis and Postpolio
Syndrome
• Management
− In-hospital care is directed at:
• Hydration
• Ventilation
• Calorie support
Poliomyelitis and Postpolio
Syndrome
• Management (cont’d)
− Prehospital treatment: managing the airway
− In-hospital treatment for postpolio includes:
• Physical therapy
• Experimental medications
Peripheral Neuropathy
• Pathophysiology
− Nerves leaving the spinal cord are damaged.
− Causes may include:
• Trauma
• Toxins
• Autoimmune attacks
Peripheral Neuropathy
• Assessment
− Signs and symptoms may include:
• Sensory or motor impairment
• Numbness
• Pain
• Muscle weakness
Peripheral Neuropathy
• Management
− Supportive in the prehospital setting
− In-hospital management includes:
• Pain medication
Hydrocephalus
• Pathophysiology
− Result of an error in the manufacture,
movement, or absorption of cerebrospinal fluid
− Two main types:
• Normal pressure
• Increased pressure
Hydrocephalus
• Assessment
(cont’d)
− Infant may have:
• Increased head
circumference
• Sun-setting eyes
• Tense or bulging
fontanelles
• Seizures
© M. Ansary/Custom Medical Stock Photo
Hydrocephalus
• Assessment (cont’d)
− Older children and adults may have:
• Headache
• Projectile vomiting
• Poor coordination
• Memory and personality impairments
Hydrocephalus
• Management
− A shunt is placed in most patients.
− Complications of shunts include:
• Inappropriate drainage of CSF
• Infection at the site
• Length of the tube may become too short.
Hydrocephalus
• Management (cont’d)
− Be prepared for seizures and increased ICP.
− Use of feeding tubes and ventilators is common.
− Do not manipulate the VP shunt.
Spina Bifida
• Pathophysiology
− Neural tube fails to close fully as embryo
develops
• Part of the nervous system remains outside the
body.
Spina Bifida
© Jones & Bartlett Learning
Spina Bifida
• Pathophysiology (cont’d)
− If an infection or chemical agent gains access,
areas of the brain can be damaged.
− A decrease in oxygen can damage the brain.
Spina Bifida
• Assessment
− Range of complications
• None to complete loss of motor and sensory
functions
− Hydrocephalus is common in children.
Spina Bifida
• Management
− The patient may be in need of multiple types of
medical technology.
− In-hospital management is supportive.
− Multivitamins are standard during pregnancy.
Cerebral Palsy
• Pathophysiology
− A developmental condition in which damage is
done to the brain
− Definite cause is unclear.
− Will not get worse over time
Cerebral Palsy
• Assessment
− Presentation begins as an infant.
− May involve:
• Walk with a scissors-like gait
• Slow, uncontrolled writhing movements
• Tremor
• Coordination difficulties
Cerebral Palsy
• Management
− Prehospital management is supportive.
− In-hospital management is symptom based.
Summary
• Neurologic problems can be dangerous.
• The central nervous system has two major
structures: the brain and the spinal cord.
• The peripheral nervous system consists of
the somatic nervous system and the
autonomic nervous system.
• Each portion of the brain is responsible for
specific functions.
Summary
• Nerve cells (neurons) transmit signals along
their axons and across synapses by means
of chemical neurotransmitters.
• A variety of disease processes can cause
neurologic dysfunction.
• Intracranial pressure is determined by the
volume of the intracranial contents.
• The primary dangers of increased
intracranial pressure are ischemia and brain
herniation.
Summary
• Investigating the neurologic patient’s chief
complaint requires taking a history to
determine the mechanism of injury or nature
of illness.
• It is critical to determine when the patient
was last seen normal because the amount
of time elapsed since the onset of
symptoms will dictate the treatments
available.
Summary
• Level of consciousness can be evaluated using:
− Glasgow Coma Scale and AVPU
− A test of corneal reflex or papillary response
− Evaluation of cranial nerve functioning
− Assessment of the patient’s orientation and alertness
− Assessment of the patient’s speech
− Evaluation of the patient’s movement
− Testing of the patient’s sensory perceptual abilities
− Testing of the blood glucose level
− Measurement of vital signs
Summary
• Following a set of standard care guidelines
can help you address common neurologic
problems in a systematic way.
• Stroke is a condition in which the blood
supply to the brain is interrupted.
• Stroke causes sudden-onset changes in
neurologic status.
• Time is brain.
Summary
• Transient ischemic attacks are episodes of
cerebral ischemia that resolve within 24
hours, leaving no permanent damage.
• A diminished level of consciousness is
marked by increasing deficits in cognition
and speech and changes in movement and
posture.
• Seizures are caused by the sudden, erratic
firing of neurons.
• Seizures have a wide range of causes.
Summary
• Seizures are classified as either generalized
or partial.
• Generalized seizures are divided into
tonic/clonic seizures, absence seizures, and
pseudoseizure.
• Simple partial seizures involve either
movement or sensations in one part of the
body. Complex partial seizures subtly
diminish the level of consciousness.
Summary
• Status epilepticus is a seizure that lasts longer
than 4 to 5 minutes or consecutive seizures
without consciousness returning between
seizures.
• Syncope is caused by a brief interruption in
cerebral blood flow that can be traced to
cardiac rhythm disturbances, other cardiac
causes, or noncardiac causes.
• Headaches can be classified as muscle
tension, migraine, cluster, or sinus headaches.
Summary
• Dementia is characterized by deterioration
of memory, personality, language skills,
perception, reasoning, or judgment, with no
loss of consciousness.
• Tumors of the neurologic system affect the
brain and spinal cord.
• Demyelinating conditions attack the
insulating sheath that surrounds and
protects the axon, so that nerve impulses
can no longer travel smoothly.
Summary
• Multiple sclerosis is an autoimmune
condition in which episodic attacks are
followed by periods of remission.
• Amyotrophic lateral sclerosis (Lou Gehrig’s
disease) is a disease that strikes the
voluntary motor neurons.
• Parkinson’s disease damages the
substantia nigra, the portion of the brain that
produces dopamine, which is needed for
muscle contraction.
Summary
• Cranial nerve disorders have a range of signs
and symptoms.
• Dystonias are severe, abnormal muscle
spasms that cause bizarre contortions,
repetitive motions, or postures.
• Encephalitis and meningitis are central nervous
system infections that cause inflammation of
the brain and meninges, respectively.
• Abscesses indicate the presence of an
infectious agent within the brain or spinal cord.
Summary
• Polio is a viral infection that can cause longterm damage to the brain and brainstem,
leading to muscle weakness and paralysis.
• Peripheral neuropathy is a group of
conditions in which the nerves leaving the
spinal cord are damaged by trauma, toxins,
tumors, autoimmune attack, and metabolic
disorders, or other processes.
Summary
• Normal-pressure hydrocephalus is a rare
condition that occurs in older adults for
unknown reasons.
• Cerebral palsy is a developmental condition
characterized by damage to the frontal lobe
of the brain. Its cause is unclear.
Credits
• Chapter opener: © Mark C. Ide
• Backgrounds: Gold—Jones & Bartlett Learning.
Courtesy of MIEMSS; Blue—Courtesy of Rhonda
Beck; Green—Courtesy of Rhonda Beck; Purple—
Courtesy of Rhonda Beck.
• Unless otherwise indicated, all photographs and
illustrations are under copyright of Jones & Bartlett
Learning, courtesy of Maryland Institute for
Emergency Medical Services Systems, or have
been provided by the American Academy of
Orthopaedic Surgeons.