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Paramedic Care: Principles & Practice
Fourth Edition
Volume 4: Medicine
CHAPTER
3
Neurology
Multimedia Directory
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Paramedic Care: Principles & Practice, 4th Ed.
Standard
• Medicine (Neurology)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Competency
• 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
complaint.
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Paramedic Care: Principles & Practice, 4th Ed.
Introduction
• Strokes attack 795,000 people every
year; 150,000 die.
• Epilepsy affects 3 million people.
• 50,000 Americans diagnosed with
Parkinson's disease each year.
• People affected by headache, multiple
sclerosis, syncope, neoplasm, other
nervous system emergencies.
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Anatomy and Physiology
• Nervous system is body's principal
control system.
• Network of cells, tissues, organs
regulates nearly all bodily functions via
electrical impulses transmitted through
nerves.
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Anatomy and Physiology
• Endocrine system: related to nervous
system; exerts control via hormones.
• Circulatory system: assists in
regulatory functions by distributing
hormones and chemical messengers.
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Anatomy and Physiology
• Central nervous system (CNS): brain
and spinal cord.
• Peripheral nervous system (PNS):
– Somatic nervous system: voluntary
functions.
– Autonomic nervous system:
sympathetic and parasympathetic
nervous system; involuntary physiologic
processes.
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Anatomy and Physiology
• Think of nervous system as a “living
computer.”
• CNS is central processing unit
• Various divisions of PNS carry on input and
output processes.
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Anatomy and Physiology
• The Central Nervous System
– Neuron: fundamental unit of nervous
system; nerve cell.
 Cell body (soma): contains nucleus.
 Dendrites: transmit electrical impulses to
cell body.
 Axons: transmit electrical impulses away
from cell body.
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Anatomy of a neuron.
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• The Central Nervous System
– In resting state, neuron positively
charged on outside; negatively charged
on inside.
– When electrically stimulated, sodium
rapidly surges into cell and potassium
rapidly leaves it to eliminate difference
in electrical charge between inside and
outside.
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Anatomy and Physiology
• The Central Nervous System
– This “depolarization,” or loss of charge
difference, is transmitted down neuron
at extremely high rate of speed.
– Neuron joins with other neurons at
junctions called synapses.
– Axon causes release of chemical
neurotransmitter (acetylcholine or
norepinephrine).
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Anatomy and Physiology
• The Central Nervous System
– Neurotransmitter stimulates
postsynaptic membrane of connecting
nerve.
– Acetylcholine: neurotransmitter of
parasympathetic and voluntary
(somatic) nervous systems.
– Norepinephrine: found in synaptic
terminals of sympathetic nerves.
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Reuptake Inhibitor Animation
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Paramedic Care: Principles & Practice, 4th Ed.
L-Dopa Animation
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• The Central Nervous System
– Brain within cranial vault, protected by
skull.
– Covered by the scalp, cranium consists
of bones of head, excluding facial
bones.
 Frontal and occipital bones.
 Parietal, temporal, sphenoids, ethmoids.
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The bones of the skull (cross section).
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The bones of the skull (profile).
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• The Central Nervous System
– 33 bones constitute the spine.
 7 cervical vertebrae
 12 thoracic vertebrae
 5 lumbar vertebrae
 5 sacral vertebrae
 4 coccygeal vertebrae
– Spinal cord housed inside; protected by
“spinal canal” formed by these bones.
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The vertebral column.
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Paramedic Care: Principles & Practice, 4th Ed.
Anatomy and Physiology
• The Central Nervous System
– Meninges: protective membranes cover
entire CNS.
 Dura mater: durable, outermost layer.
 Arachnoid membrane: middle layer;
weblike structure.
 Pia mater: innermost layer, directly
overlying CNS.
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Anatomy and Physiology
• The Central Nervous System
– Both brain and spinal cord bathed in
cerebrospinal fluid; watery, clear fluid
that acts as cushion.
– Brain largest part of CNS.
– Brain divided into six major parts:
 Cerebrum, diencephalon, pons,
mesencephalon, medulla oblongata,
cerebellum.
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Anatomy and Physiology
• The Central Nervous System
– Cerebrum
 Governs all sensory and motor actions.
 Intelligence, learning, analysis, memory,
language.
 Cerebral cortex outermost layer of
cerebrum.
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Anatomy and Physiology
• The Central Nervous System
– Diencephalon (interbrain)
 Inside are thalamus, hypothalamus,
limbic system.
 Involuntary actions: temperature
regulation, sleep, water balance, stress
response, emotions.
 Major role in regulating autonomic
nervous system.
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Anatomy and Physiology
• The Central Nervous System
– Mesencephalon (midbrain), pons, and
medulla oblongata collectively form
brainstem; brainstem and cerebellum
constitute hindbrain.
– Mesencephalon: responsible for certain
aspects of motor coordination.
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Anatomy and Physiology
• The Central Nervous System
– Pons: connection between brain and
spinal cord.
– Medulla oblongata: center for controlling
respiration, cardiac activity, vasomotor
activity.
– Cerebellum: coordinates fine motor
movement, posture, equilibrium, muscle
tone.
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Anatomy and Physiology
• The Central Nervous System
– Speech: located in temporal lobe of
cerebrum.
– Vision: located in occipital cortex of
cerebrum.
– Personality: located in frontal lobes of
cerebrum.
– Balance and coordination: located in
cerebellum.
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Anatomy and Physiology
• The Central Nervous System
– Sensory: located in parietal lobes of
cerebrum.
– Motor: located in frontal lobes of
cerebrum.
– Reticular activating system: responsible
for maintaining consciousness and
ability to respond to stimuli.
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External anatomy of the brain.
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Anatomy and Physiology
• The Central Nervous System
– Brain receives about 20% of body's total
blood flow per minute.
– Accounts for only 2% of body weight.
– Consumes 25% of body's glucose.
– Carotid system anterior; vertebrobasilar
system posterior; both join at circle of
Willis.
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Anatomy and Physiology
• The Central Nervous System
– Besides blood flow, cerebrospinal fluid
bathes brain and spinal cord.
– Several chambers within brain
(ventricles) contain most of intracranial
volume of this fluid.
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Anatomy and Physiology
• The Central Nervous System
– Spinal cord 17–18 inches long.
– Responsible for conducting impulses to
and from peripheral nervous system and
for reflexes.
– Thirty-one pairs of nerve fibers exit
spinal cord as it descends and enters
PNS.
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Sectional view of the spinal cord showing distribution of spinal nerves.
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Anatomy and Physiology
• The Central Nervous System
– Afferent (sensory) fibers transmit
impulses to CNS from body.
– Efferent (motor) fibers carry impulses
from CNS to body.
– Each nerve root has corresponding area
of skin (dermatome) to which it supplies
sensation.
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Anatomy and Physiology
• The Central Nervous System
– Reflexes are protective.
– Spinal cord stimulates appropriate
muscles to remove part of body closest
to perceived threat.
– Reflex actions lack fine motor control.
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Anatomy and Physiology
• The Peripheral Nervous System
– Consists of cranial and peripheral
nerves; both voluntary and involuntary
components.
– 12 pairs of cranial nerves originate in
brain; supply nervous control to head,
neck, certain thoracic and abdominal
organs.
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Anatomy and Physiology
• The Peripheral Nervous System
– Somatic sensory: afferent nerves
transmit sensations involved in touch,
pressure, pain, temperature, position.
– Somatic motor: efferent fibers carry
impulses to skeletal (voluntary)
muscles.
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Anatomy and Physiology
• The Peripheral Nervous System
– Visceral (autonomic) sensory: afferent
tracts transmit sensations from visceral
organs.
– Visceral (autonomic) motor: efferent
fibers exit CNS and branch to supply
nerves to involuntary cardiac muscle
and smooth muscle of viscera (organs)
and to glands.
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Anatomy and Physiology
• The Automatic Nervous System
– Involuntary component of PNS:
responsible for unconscious control of
many body functions.
– Sympathetic and parasympathetic
systems are antagonistic.
– During stress, sympathetic system
dominates; during rest,
parasympathetic system dominates.
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Anatomy and Physiology
• The Sympathetic Nervous System
– Referred to as “fight-or-flight” system.
– Prepares body for stressful situations.
– Stimulation causes increased heart rate
and blood pressure, pupillary dilation,
rise in blood sugar, bronchodilation.
– Neurotransmitters epinephrine and
norepinephrine mediate its actions.
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Anatomy and Physiology
• The Parasympathetic Nervous System
– “Feed-or-breed” system; responsible for
controlling vegetative functions (normal
heart rate and blood pressure).
– Mediated by acetylcholine.
– When stimulated: decrease in heart
rate, increase in digestive activity,
pupillary constriction, reduction in blood
glucose.
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Pathophysiology
• Consciousness: individual fully
responsive to stimuli and demonstrates
awareness of environment.
• Altered forms of consciousness can
result from dysfunction or interruption
of CNS.
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Pathophysiology
• Central Nervous System Disorders
– Alteration in mental status hallmark sign
of CNS injury or illness.
– Any alteration in mental status is
abnormal; warrants examination.
– Unconsciousness (coma): patient cannot
be aroused, even by powerful external
stimuli.
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Pathophysiology
• Central Nervous System Disorders
– Structural lesions: depress
consciousness by destroying or
encroaching on substance of brain.
 Brain tumor (neoplasm)
 Degenerative disease
 Intracranial hemorrhage
 Parasites
 Trauma
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Pathophysiology
• Central Nervous System Disorders
– Toxic-metabolic states: presence of
circulating toxins or metabolites or lack
of metabolic substrates.
 Anoxia
 Diabetic ketoacidosis
 Hepatic failure
 Hypercapnia
 Hypoglycemia
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Pathophysiology
• Central Nervous System Disorders
– Toxic-metabolic states
 Renal failure
 Thiamine deficiency
 Toxic exposure
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Pathophysiology
• Altered Mental Status Common Causes
– Drugs
 Depressants (including alcohol)
 Hallucinogens
 Narcotics
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Pathophysiology
• Altered Mental Status Common Causes
– Cardiovascular
 Anaphylaxis
 Cardiac arrest
 Stroke
 Arrhythmias
 Hypertensive encephalopathy
 Shock
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Pathophysiology
• Altered Mental Status Common Causes
– Respiratory
 Chronic obstructive pulmonary disease
(COPD)
 Inhalation of toxic gas
 Hypoxia
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Pathophysiology
• Altered Mental Status Common Causes
– Infectious
 AIDS
 Encephalitis
 Meningitis
 Parasites
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Pathophysiology
• Autonomic nervous system (ANS):
maintains cerebral homeostasis
(internal balance); regulates and
coordinates body's vital functions.
– Blood pressure
– Temperature regulation
– Respiration
– Metabolism
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Pathophysiology
• Peripheral Nervous System Disorders
– Peripheral neuropathy: any malfunction
or damage of peripheral nerves.
– Can affect muscle activity, sensation,
reflexes, internal organ function.
– Mononeuropathy caused by localized
conditions (trauma, compression,
infections).
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Pathophysiology
• Peripheral Nervous System Disorders
– Polyneuropathy: demyelination or
degeneration of peripheral nerves.
 Leads to sensory, motor, or mixed
sensorimotor deficits.
 Causes: immune disorders, toxic agents,
metabolic disorders.
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Pathophysiology
• Autonomic Nervous System Disorders
– Frequently result of another condition.
– Most conditions that affect integrity of
individual are accompanied by some
changes in autonomic nervous system
functioning.
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General Assessment Findings
• Size up scene and surroundings as well
as patient to form general impression.
• Evaluate mental status before
assessing ABCs.
– General appearance
– Speech
– Skin
– Posture/gait
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General Assessment Findings
• Quickly check patient's mental status
through “AVPU” method.
– A: patient alert and aware of
surroundings.
– V: patient responds to verbal stimuli.
– P: patient responds to painful stimuli.
– U: patient unresponsive.
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General Assessment Findings
• Assess patient's emotional status.
– Alteration from normal mental status or
mood considered significant; warrants
additional assessment.
 Mood
 Thought
 Perception
 Judgment
 Memory and attention
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General Assessment Findings
• Once level of consciousness
determined, place greatest emphasis
on maintenance of airway.
• If unconscious, assume cervical spine
injury exists; treat appropriately.
– Use modified jaw-thrust maneuver.
– Once opened, insert appropriate airway
adjunct.
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General Assessment Findings
• In unresponsive, tongue may be
occluding airway.
– Place oropharyngeal or nasopharyngeal
airway to maintain patency.
• Essential to observe for respiratory
arrest that can result from increased
intracranial pressure.
• Remain alert for absent gag reflex and
vomiting.
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General Assessment Findings
• Observe for signs and symptoms of
inadequate or impaired breathing or
abnormal respiratory patterns.
• Evaluate heart rate, rhythm,
electrocardiogram (ECG) pattern.
• Observe skin color, temperature,
moisture.
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General Assessment Findings
• Secondary assessment: history and
physical exam, including vital signs.
• Determine whether neurologic problem
traumatic or medical.
– Clarification will determine plan for
subsequent prehospital treatment.
– Obtain information from family, friends,
or other bystanders.
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General Assessment Findings
• Physical examination: standard headto-toe examination; more detailed
neurologic assessment.
– Pay particular attention to pupils,
respiratory status, spinal evaluation.
– Note any drooping or facial paralysis.
– If both pupils dilated and do not react to
light, patient probably has brainstem
injury or suffered serious brain anoxia.
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General Assessment Findings
• Physical Examination
– Unilaterally dilated pupil that remains
reactive to light may be sign of
increasing intracranial pressure.
– Constricted (pinpoint) pupils suggest
toxic etiology for altered mental status.
– Assess extraocular movement: have
patient follow finger movements.
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General Assessment Findings
• Physical Examination
– Important to check for contact lenses.
– Pay particular attention to any changes
that potentially compromise airway.
– Respiratory derangement can occur with
CNS illness or injury.
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General Assessment Findings
• Abnormal Respiratory Patterns
– Cheyne-Stokes respirations
– Kussmaul's respirations
– Central neurogenic hyperventilation
– Ataxic respirations
– Apneustic respirations
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General Assessment Findings
• Physical Examination
– Normal blood PaCO2 is 40 mmHg.
– Increasing PaCO2 causes cerebral
vasodilation; decreasing it results in
cerebral vasoconstriction.
– Patients with neurologic dysfunction
have worse outcomes when excessive
oxygen (hyperoxia) administered.
– Assess the SpO2.
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General Assessment Findings
• Physical Examination
– Vigilant assessment of vital signs to
observe following changes:
 Heart rate
 ECG/rhythm
 Bruits
 Jugular venous distention (JVD)
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General Assessment Findings
• Nervous System Status
– Sensorimotor evaluation: document loss
of sensation and/or motor function.
– Suspected spinal cord injury will require
full immobilization on long spine board.
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General Assessment Findings
• Nervous System Status
– Both decorticate and decerebrate
posturing are ominous signs of deep
cerebral or upper brainstem injury.
– Flaccid paralysis indicates spinal cord
injury.
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Patient with decorticate posturing.
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Patient with decerebrate posturing.
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General Assessment Findings
• Motor System Status
– Assessment
 Muscle tone
 Strength
 Flexion
 Extension
 Coordination
 Balance
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General Assessment Findings
• Cranial nerves: proper and intact
functioning assessed during complete
neurologic examination.
• Glasgow coma scale (GCS); total score
indicator of survival.
– Eye opening
– Verbal response
– Motor response
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General Assessment Findings
• Vital Signs
– Increased intracranial pressure:
changes in vital signs (Cushing's triad).
 Increased blood pressure
 Decreased pulse
 Irregular respirations
– Continuous ECG monitoring and pulse
oximetry to spot early signs of CNS
lesions.
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General Assessment Findings
• Capnography: monitors amount of
carbon dioxide being exhaled by patient
while being ventilated.
• Pulse oximeter: tool for monitoring
patient's general state of perfusion.
• Blood glucose meter: obtain accurate
blood glucose level.
• CO-oximetry: detection of elevated CO
levels possible in prehospital setting.
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General Assessment Findings
• Geriatric Considerations
– Neurologic system susceptible to
systemic illness and often by other body
disorders.
– Level of consciousness and mental
status evaluated by assessing
judgment, memory, affect, mood,
orientation, speech, grooming.
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General Assessment Findings
• Geriatric Considerations
– Interview family members.
– Problems: headache, low back pain,
dizziness, weakness, loss of balance,
disorders such as Parkinson's disease,
and vascular emergencies such as
stroke.
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General Assessment Findings
• Any patient suffering from neurologic
emergency should be reassessed every
5 minutes during your care and during
transportation.
• Constantly reevaluate and monitor
airway and neurologic system.
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Management of Specific Nervous
System Emergencies
• Primary treatment for nervous system
emergencies in field is supportive.
– Airway and breathing
– Circulatory support
– Pharmacological interventions
– Psychological support
– Transport considerations
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– AEIOU-TIPS
 A = Acidosis, alcohol
 E = Epilepsy
 I = Infection
 O = Overdose
 U = Uremia (kidney failure)
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– AEIOU-TIPS
 T = Trauma, tumor, toxin
 I = Insulin (hypoglycemia or diabetic
ketoacidosis)
 P = Psychosis, poison
 S = Stroke, seizure
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– Determine underlying cause.
– Determine level of consciousness.
– Unresponsive patients require vigilant
monitoring and protection of airway.
– Initial priority: ensure airway open and
cervical spine immobilized.
– Assess circulatory status.
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– Establish IV with saline lock.
– Determine blood glucose level.
– If blood glucose level low, administer
50% dextrose.
– Administer naloxone if suspected
narcotic overdose.
– If suspected alcoholic, consider
administration of 100 mg of thiamine.
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– Chronic alcoholism interferes with
intake, absorption, use of thiamine.
– Wernicke's syndrome: acute but
reversible encephalopathy; ataxia, eye
muscle weakness, mental derangement.
– Korsakoff's psychosis: memory
disorder; may be irreversible.
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Management of Specific Nervous
System Emergencies
• Altered Mental Status
– Increase in intracranial pressure:
ventilate patient at 10–12 breaths per
minute.
– Mannitol causes diuresis.
– As with all medications, follow local
protocols.
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Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Stroke (brain attack): injury or death of
brain tissue usually due to interruption
of cerebral blood flow.
– Early recognition and rapid transport to
hospital crucial to improving outcome
for stroke patients.
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Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Tissue plasminogen activator (tPA) and
fibrinolytic agents effective in treating
certain occlusive strokes.
– Third most common cause of death;
frequent cause of disability.
– Serious, potentially life-threatening
condition.
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Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Occlusive stroke: cerebral artery
blocked by clot or other foreign matter.
 Results in ischemia, an inadequate blood
supply to brain tissue.
 Progresses to infarction, death of tissues
as result of cessation of blood supply.
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Causes of stroke.
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Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Embolic strokes: embolus is solid, liquid,
or gaseous mass carried to blood vessel
from remote site.
– Emboli are clots (thromboemboli); arise
from diseased blood vessels in neck
(carotid) or abnormally contracting
chambers in heart.
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Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Other types of emboli that cause
occlusion in cerebral blood vessels: air,
tumor tissue, fat.
– Embolic strokes occur suddenly;
characterized by severe headaches.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Thrombotic strokes: cerebral thrombus
is blood clot that gradually develops in
and obstructs cerebral artery.
– Atherosclerosis
 Plaque deposits form on inner walls of
arteries; buildup causes narrowing of
arteries; reduces amount of blood that
can flow through them.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Signs and symptoms of thrombotic
stroke develop gradually.
– Often occurs at night; characterized by
patient awakening with altered mental
status and/or loss of speech, sensory,
or motor function.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Hemorrhagic strokes: categorized as
being within brain (intracerebral) or in
space around outer surface of brain
(subarachnoid).
– Onset often sudden; marked by severe
headache.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Most intracranial hemorrhages occur in
hypertensive patient when small vessel
deep within brain tissue ruptures.
– Subarachnoid hemorrhages most often
result from congenital blood vessel
abnormalities or from head trauma.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Etiologies of stroke.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Signs and symptoms of stroke will
depend on type of stroke and area of
brain damaged.
– Areas commonly affected: motor,
speech, sensory centers.
– Onset of symptoms will be acute;
patient may experience
unconsciousness.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Signs and symptoms of stroke include:
– Facial drooping
– Headache
– Confusion and agitation
– Dysphasia
– Aphasia
– Dysarthria
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Signs and symptoms of stroke include:
– Vision problems such as monocular
blindness or double vision
– Hemiparesis
– Hemiplegia
– Paresthesia
– Inability to recognize by touch
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Signs and symptoms of stroke include:
– Gait disturbances or uncoordinated fine
motor movements
– Dizziness
– Incontinence
– Coma
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Predisposing factors:
 Hypertension
 Diabetes
 Abnormal blood lipid levels
 Oral contraceptives
 Sickle cell disease
 Some cardiac arrhythmias (atrial
fibrillation)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Prehospital Stroke Scoring Systems
– Los Angeles Prehospital Stroke Screen
(LAPSS)
 Assesses blood glucose levels, facial
droop, grip strength, arm (pronator)
drift.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Facial droop.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Arm drift.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Prehospital Stroke Scoring Systems
– Cincinnati Prehospital Stroke Scale
(CPSS)
 Evaluates facial droop, arm drift, speech.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Transient ischemic attacks (TIAs):
transient stroke-like symptoms.
 Temporary interference with blood supply
to brain, producing symptoms of
neurologic deficit.
 Last for few minutes or for several hours;
usually resolve within 24 hours.
 No evidence of residual brain or
neurologic damage.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Patient who experiences TIA may be a
candidate for eventual stroke.
– Considered high-risk events.
– Onset usually abrupt.
– Any one or combination of stroke
symptoms may be present.
– Common cause is carotid artery disease.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Suspected of TIA
 Previous neurologic symptoms
 Initial symptoms and their progression
 Changes in mental status
 Precipitating factors
 Dizziness
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Suspected of TIA
 Palpitations
 History of hypertension, cardiac disease,
sickle cell disease, previous TIA or stroke
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Care for stroke or TIA
 Early recognition
 Supportive measures
 Rapid transport
 Notification of emergency department
 Aggressive airway management is
priority
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Care for stroke or TIA
 Ensure scene safety, including Standard
Precautions.
 Establish and maintain adequate airway.
 If apneic or if breathing inadequate,
provide positive pressure ventilations at
rate of 10–12 per minute.
 Check for hypoxia with pulse oximetry.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Care for stroke or TIA
 Complete detailed patient history.
 Perform stroke assessment.
 Keep patient supine or in recovery
position.
 Determine blood glucose level.
 Place saline lock.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Stroke and Intracranial Hemorrhage
– Care for stroke or TIA
 Monitor cardiac rhythm, oximetry,
capnography.
 Protect paralyzed extremities.
 Give patient reassurance.
 Rapidly transport.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Generalized: begin as electrical
discharge in small area of brain but
spread to involve entire cerebral cortex,
causing widespread malfunction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Partial: may remain confined to limited
portion of brain, causing localized
malfunction, or may spread and become
generalized.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Epilepsy Video
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Generalized seizures include tonic-clonic
and absence seizures.
– Tonic-clonic (grand mal seizure):
generalized motor seizure, producing
loss of consciousness.
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Paramedic Care: Principles & Practice, 4th Ed.
Grand Mal Seizure Video
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Tonic (increased tone) phase: tensed,
contracted muscles
– Clonic phase: rhythmic jerking
movements of extremities.
– Specific progression of events.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Tonic-clonic seizures have specific
progression of events:
 Aura
 Loss of consciousness
 Tonic phase; hypertonic phase
 Clonic phase
 Post seizure
 Postictal
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Absence (petit mal seizure): brief,
generalized seizure; 10- to 30-second
loss of consciousness or awareness, eye
or muscle fluttering, occasional loss of
muscle tone.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Pseudoseizures (hysterical seizures):
stem from psychological disorders.
– Patient presents with sharp and bizarre
movements that can often be
interrupted with terse command.
– Very rarely do patients experiencing
pseudoseizure injure themselves.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Partial seizures: simple or complex.
 Simple partial seizures (focal motor, focal
sensory, or Jacksonian seizures): chaotic
movement or dysfunction of one area of
body.
 No loss of consciousness; frequently
spread.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Partial seizures: simple or complex.
 Complex partial (temporal lobe or
psychomotor seizures):distinctive auras.
 Unusual smells, tastes, sounds, or
tendency of objects to look very large
and near or small and distant.
 Metallic taste in mouth common.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Complex Partial Seizure Video
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Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Ascertain exactly what patient may
recall or what bystanders witnessed.
– Many other problems can mimic or
suggest seizure.
– If unsure whether patient had seizure, it
may be more harmful than beneficial to
administer anticonvulsant medication.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Distinguish between syncope and true
seizure.
– History of seizures.
– Recent history of head trauma.
– Any alcohol and/or drug abuse.
– Recent history of fever, headache, stiff
neck.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– History of diabetes, heart disease, or
stroke.
– Current medications.
– Note signs of head trauma or injury to
tongue.
– Determine blood glucose level.
– Check for hypoxia.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Note any evidence of alcohol and/or
drug abuse.
– Document arrhythmias.
– Ensure scene safety.
– Maintain airway.
– Administer supplemental oxygen to
correct hypoxia.
– Establish intravenous access.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Determine blood glucose level.
– Never attempt to restrain patient.
– Maintain body temperature.
– Position patient on left side after tonicclonic phase.
– Suction, if required.
– Monitor cardiac rhythm, oximetry,
capnography.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Protection of a seizing patient.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Place a seizing patient with no suspected spine injury on her left side.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– If seizure prolonged (> 5 minutes),
consider anticonvulsant.
– Provide quiet, reassuring atmosphere.
– Transport patient in supine or lateral
recumbent position.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Status epilepticus: series of two or more
generalized motor seizures without
intervening return of consciousness.
 Common cause: failure to take
prescribed anticonvulsant medications.
 Involves prolonged period of apnea; can
cause hypoxia of vital brain tissues.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Status epilepticus
 Protect patient from airway obstruction;
deliver 100% oxygen.
 Start IV of normal saline, keep-open
rate.
 Monitor cardiac rhythm, oximetry,
capnography.
 Administer 25 g of 50% dextrose IV
push.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Types of Seizures
– Status epilepticus
 Administer 5–10 mg diazepam IV push
for adult.
 Continue to monitor airway.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Diazepam Animation
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©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Syncope (fainting): neurologic
condition; sudden, temporary loss of
consciousness caused by insufficient
blood flow to brain; recovery of
consciousness on becoming supine.
– Cardiovascular conditions
– Hypovolemia
– Noncardiovascular disease
– Idiopathic, or unknown cause
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Syncope (fainting)
– Identify underlying cause and treat it.
– Ensure scene safety.
– Establish and maintain adequate airway.
– Administer supplemental oxygen to
correct hypoxia. Avoid hyperoxia.
– Check circulatory status.
– Check and monitor mental status.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Syncope (fainting)
– Obtain IV access.
– Determine blood glucose level.
– Monitor ECG, oximetry, capnography.
– Reassure patient.
– Transport to emergency department.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Headache
– Can be acute (sudden onset); chronic
(constant or recurring); generalized (all
over); localized (in one specific area).
– Can range from mild to severe.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Headache
– Vascular headaches include migraines
and cluster headaches.
– Significant percentage are tension
headaches.
– Organically caused headaches.
– Continuous throbbing headache with
fever, confusion, nuchal rigidity classic
signs and symptoms of meningitis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Headache
– Complaints of nausea, vomiting, blurred
vision, dizziness, weakness, watery
eyes.
– Complete and thorough history crucial
to treatment.
– Headache of acute onset or of changing
pattern demands immediate attention.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Headache
– Ensure scene safety.
– Establish and maintain adequate airway.
– Place patient in position of comfort.
– Administer supplemental oxygen to
correct hypoxia. Avoid hyperoxia.
– Obtain IV access.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Headache
– Determine blood glucose level.
– Monitor ECG, oximetry, capnography.
– Reassure patient.
– Consider antiemetics or pain-control
measures.
– Ensure calm, quiet environment.
– Transport to emergency department.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Cranial Nerve Disorders
– Affects connection between cranial
nerve centers of brain and particular
tissues innervated by those nerves.
– Signs and symptoms depend on nerve
involved.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Cranial Nerve Disorders
– Bell's palsy: sudden, unilateral
weakness or paralysis of facial muscles;
due to dysfunction of seventh cranial
nerve (facial nerve).
 Treatment: antiviral drugs.
 In most instances, resolves completely
without any residual deficits.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Bell's palsy. (© Michal Heron)
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Cranial Nerve Disorders
– Trigeminal neuralgia (tic doloureux):
extremely painful disorder that affects
fifth cranial nerve (trigeminal nerve).
 Electrical-shock-type spasms and pain.
 Tends to be chronic condition.
 Antiseizure drugs used in treatment.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Weak and Dizzy
– Can be symptoms of many diseases.
– Obtain more detailed history of illness.
– Focused assessment, including
neurologic examination.
– Be alert for presence of nystagmus.
– Determine if localized or diffuse.
– Be alert for potential causes.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Weak and Dizzy
– Ensure scene safety.
– Establish and maintain adequate airway.
– Place patient in position of comfort,
generally with head elevated.
– Administer supplemental oxygen to
correct hypoxia. Avoid hyperoxia.
– Obtain IV access.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Weak and Dizzy
– Check blood glucose level.
– Monitor ECG, oximetry, capnography.
– Consider administration of antiemetic.
– Consider analgesic therapy with opiate.
– Ensure calm, quiet environment.
– Reassure patient.
– Transport to emergency department.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Neoplasms
– New growth of tumor.
– Benign (noncancerous) tumors:
composed of cells that grow similarly to
normal cells, grow relatively slowly,
confined to one location.
– Malignant (cancerous) tumors: growth
very different from that of normal cells;
grow quickly and spread to other sites.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Neoplasms
– Any tumor located near any of vital
structures of brain may seriously
threaten ability to breathe, move, or
regulate other bodily functions.
– Most brain tumors metastases from
cancer that started somewhere else in
body.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Signs and Symptoms of Neoplasm
– Headache (often severe and recurring
frequently)
– New seizures in adult with no history of
seizure disorder
– Nausea
– Vomiting
– Behavioral or cognitive changes
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Signs and Symptoms of Neoplasm
– Weakness or paralysis or change in
sensation of one or more limbs or side
of face
– Lack of coordination
– Difficulty walking or unsteady gait
– Dizziness
– Double vision
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Neoplasms
– Ensure scene safety.
– Establish and maintain adequate airway.
– Place patient in position of comfort,
generally with head elevated.
– Administer supplemental oxygen to
correct hypoxia.
– Obtain IV access.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Neoplasms
– Monitor ECG, oximetry, capnography.
– Consider narcotic analgesia.
– Consider diazepam if seizure activity is
present.
– Anti-inflammatories (dexamethasone)
and diuretics may be requested by
medical direction.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Neoplasms
– Ensure calm, quiet environment.
– Reassure patient.
– Transport to emergency department.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Brain Abscess
– Collection of pus localized in area of
brain; uncommon.
– Headache, lethargy, hemiparesis,
seizures, nuchal rigidity, nausea,
vomiting, fever.
– Management: supportive.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Collection of diseases; selectively affect
one or more functional systems of CNS.
– Alzheimer's disease
 Results from death and disappearance of
nerve cells in cerebral cortex; marked
atrophy of brain.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Pick's disease
 Permanent form of dementia similar to
Alzheimer's disease
 Tends to affect only certain areas of
brain; rare.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Huntington's disease (Huntington's
chorea)
 Caused by genetic defect in chromosome
4; adult-onset and early-onset types.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Creutzfeldt-Jakob disease (CJD)
 Form of brain damage; leads to rapid
decrease in mental function and
movement.
 Results from protein called prion; rare.
 There is no treatment.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Muscular dystrophy (MD)
 Group of genetic diseases characterized
by progressive muscle weakness and
degeneration of skeletal or voluntary
muscle fibers.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Multiple sclerosis (MS)
 Unpredictable disease of CNS.
 Inflammation of certain nerve cells
followed by demyelination, or
destruction, of myelin sheath.
 Nerves unable to properly conduct
impulses.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Guillain-Barré syndrome
 Serious disorder.
 Body's defense (immune) system
mistakenly attacks peripheral nerves,
leading to nerve inflammation that
causes muscle weakness.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Dystonias
 Group of disorders; muscle contractions
cause twisting and repetitive
movements, abnormal postures, freezing
in middle of action.
 Such movements involuntary and
sometimes painful.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Parkinson's disease
 Belongs to group of conditions known as
motor system disorders.
 Chronic and progressive disorder.
 Four characteristics: tremor, rigidity,
bradykinesia, postural instability.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Central pain syndrome
 Results from damage or injury to brain,
brainstem, or spinal cord.
 Intense, steady pain; burning, aching,
tingling, “pins-and-needles” sensation.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Amyotrophic lateral sclerosis (ALS) (Lou
Gehrig's disease)
 Progressive degeneration of specific
nerve cells that control voluntary
movement.
 Motor neuron disease.
 There is no cure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Myoclonus
 Temporary, involuntary twitching or
spasm of muscle or group of muscles.
 Considered not diagnosis but symptom.
 Treatment: medications to reduce
symptoms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Spina bifida (SB)
 Neural defect; results from failure of one
or more of fetal vertebrae to close
properly during pregnancy.
 Leaves portion of spinal cord
unprotected.
 Nerve damage permanent; no cure.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Spina bifida (SB) common types
 Myelomeningocele
 Meningocele
 Occulta
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Degenerative Neurologic Disorders and
Dementia
– Poliomyelitis (polio)
 Infectious, inflammatory viral disease of
CNS that sometimes results in
permanent paralysis.
 New cases rare.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Assessment of Degenerative Neurologic
Disorders
– Determine chief complaint.
– Conduct primary assessment.
– Correct any life-threatening problems.
– Find out what prompted call to EMS.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Management of Degenerative
Neurologic Disorders
– Treat chief complaint as priority.
– Consider the following:
 Mobility
 Communication
 Respiratory compromise
 Anxiety
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Management of Degenerative
Neurologic Disorders
– Determine blood glucose level.
– Obtain IV access.
– Monitor ECG.
– Transport to emergency department.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Low back pain (LBP): most common
back pain complaint; can be debilitating.
– Felt between lower rib cage and gluteal
muscles, often radiating to thighs.
– Sciatica: severe pain along path of
sciatic nerve, down back of thigh and
inner leg.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Nontraumatic spinal injuries
 Degeneration or rupture of disks that
separate vertebrae.
 Degeneration or fracture of vertebrae.
 Cyst or tumor that impinges on spine.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Disk injury
 Cartilaginous disks that separate
vertebrae may rupture as result of injury
or rupture or degenerate as part of
aging.
 Herniated disk: gelatinous center of disk
extrudes through tear in outer capsule.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Vertebral injury
 Vertebrae themselves break down
(vertebral spondylolysis).
 Heredity a factor.
 Spinal fractures frequently associated
with osteoporosis.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Cyst or tumor along spine or intruding
into spinal canal may cause pain by
pressing on spinal cord, by causing
degenerative changes in bone, or by
interrupting blood supply.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Cauda equina syndrome
 Significant narrowing of spinal canal that
compresses nerve roots below level of
spinal cord.
 Trauma, disk herniation, spinal stenosis,
spinal tumors, inflammation, infection.
 Decompressive surgery often necessary.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Referred pain: from disorders such as
diabetic neuropathy, renal calculus,
abdominal aortic aneurysm, many other
conditions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Assessment based on chief complaint,
history, physical exam.
– Precise diagnosis likely difficult.
– Determine if pain caused by lifethreatening or non-life-threatening
condition.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Management of Specific Nervous
System Emergencies
• Back Pain and Nontraumatic Spinal
Disorders
– Prehospital management
 Aimed at decreasing pain or discomfort.
 Keep watchful eye for signs and
symptoms of serious underlying disorder.
 If in doubt, immobilize, remembering the
injunction to “do no harm.”
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Nervous system can be thought of as
complex system of computer processors
(CNS) and wiring (PNS) responsible for
entirety of body functions.
• When abnormality occurs, signs and
symptoms include reduced ability or
inability to complete task or function that
otherwise would normally occur.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Brain is the control center for all
functions of body.
• Whenever there is interruption in blood
supply to any part of brain, result will
be inability to perform associated
function or functions.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• EMS personnel should know the 12
cranial nerves, or, at minimum, how to
assess each one.
• Thorough neurologic assessment of all
12 cranial nerves helps to quickly
identify abnormalities and even specific
area of brain affected.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• In all neurologic emergencies, it is
imperative to address airway and
oxygenation first, followed closely by
general assessment, making sure to
use available diagnostic tools.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Keep in mind that the brain is largely
powered by glucose and oxygen.
• If the level of either of these becomes
altered, the patient is likely to present
with neurologic symptoms.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Your first assessment tools should
include blood glucose assessment and
pulse oximetry.
• Always treat hypoglycemia in
neurologically impaired patients,
because often hypoglycemia is the
cause and is easily corrected with
dextrose.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Neurologic emergencies often present
with altered level of consciousness up
to and including coma.
• Rapid identification and treatment of
possible causes (AEIOU-TIPS) with
rapid transport to closest appropriate
facility is imperative.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• For neurologic impairment (especially
for stroke), treatment is very time
sensitive (definitive treatment must
occur within 4.5 hours from onset).
• Rapid treatment is essential for best
possible outcomes.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Whether you are treating a possible
stroke, seizure, coma, or headache,
your treatment must remain focused on
assessing and maintaining patient's
airway, oxygen, and glucose levels.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Rapid identification and early
notification to your receiving facility are
key in achieving successful recovery
from strokes and other neurologic
impairments.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.
Summary
• Often, care for neurologic patient may
simply be supportive; in other cases,
you will need to provide drug therapy
or other interventions to limit or reduce
presenting symptoms.
• In every case, airway management
remains your priority.
©2013 Pearson Education, Inc.
Paramedic Care: Principles & Practice, 4th Ed.