Neurology

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Neurology

  1. 1. Neurology Chapter #31 Jason N. Cook Emergency Care & Rescue Weber State University
  2. 2. Pathophysiology of CNS Emergencies <ul><li>Structural Changes </li></ul><ul><ul><li>Often due to Trauma but not always </li></ul></ul><ul><ul><li>Circulatory Changes </li></ul></ul><ul><ul><ul><li>Inadequate Perfusion </li></ul></ul></ul><ul><ul><li>Alterations of ICP </li></ul></ul><ul><ul><ul><li>Response to insult </li></ul></ul></ul><ul><li>Toxic Metabolic states </li></ul><ul><ul><li>Alteration to blood chemistry or introduction of toxins </li></ul></ul><ul><li>Psychiatric ‘mimicking’ </li></ul>
  3. 3. Nervous System Anatomy <ul><li>Two parts </li></ul><ul><ul><li>Central nervous system (CNS) </li></ul></ul><ul><ul><li>Peripheral nervous system (PNS) </li></ul></ul><ul><li>CNS </li></ul><ul><ul><li>Brain </li></ul></ul><ul><ul><li>Spinal cord </li></ul></ul><ul><ul><ul><li>Both encased in and protected by bone </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  4. 4. Peripheral Nervous System <ul><li>43 pairs of nerves originate from CNS to form PNS </li></ul><ul><ul><li>12 pairs of cranial nerves </li></ul></ul><ul><ul><ul><li>Originate from brain </li></ul></ul></ul><ul><ul><li>31 pairs of spinal nerves </li></ul></ul><ul><ul><ul><li>Originate from spinal cord </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  5. 5. Cells of the Nervous System <ul><li>Neurons—fundamental units </li></ul><ul><li>Neuroglia—connective tissue cells </li></ul><ul><ul><li>Protect and hold neurons together </li></ul></ul><ul><li>Neurons </li></ul><ul><ul><li>Cell body—single nucleus and nucleolus </li></ul></ul><ul><ul><li>Dendrites—branching projections </li></ul></ul><ul><ul><li>Axon—single, elongated projection </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  6. 6. Cells of the Nervous System Neuron with dendrites, cell body, axon Neuron
  7. 7. Cells of the Nervous System <ul><li>Dendrites transmit impulses to neuron cell bodies </li></ul><ul><li>Axons transmit impulses away from cell bodies </li></ul><ul><ul><li>Bundles of parallel axons with sheaths are white </li></ul></ul><ul><ul><ul><li>White matter </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  8. 8. Cells of the Nervous System <ul><li>In PNS, bundles of axons and their sheaths are called nerves </li></ul><ul><ul><li>Collections of nerve cells are gray </li></ul></ul><ul><ul><ul><li>Gray matter </li></ul></ul></ul><ul><ul><li>Gray matter is integration site within nervous system </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  9. 9. Types of Neurons <ul><li>Classified by impulse transmission direction: </li></ul><ul><ul><li>Sensory neurons </li></ul></ul><ul><ul><ul><li>Afferent neurons </li></ul></ul></ul><ul><ul><li>Motor neurons </li></ul></ul><ul><ul><ul><li>Efforent neurons </li></ul></ul></ul><ul><ul><li>Interneurons </li></ul></ul><ul><ul><ul><li>Connecting neurons </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  10. 10. Impulse Transmission <ul><li>Nervous system transmission similar to electrical impulse conduction in heart </li></ul><ul><li>Unmyelinated axons </li></ul><ul><li>Myelinated axons </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  11. 11. Nerve Impulse Conduction Unmyelinated fiber Myelinated fiber Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  12. 12. Synapse <ul><li>Membrane-to-membrane contact </li></ul><ul><li>Separates axon endings of one neuron (presynaptic neuron) from dendrites of another neuron (postsynaptic neuron) </li></ul><ul><ul><li>Presynaptic terminal </li></ul></ul><ul><ul><li>Synaptic cleft </li></ul></ul><ul><ul><li>Plasma membrane of postsynaptic neuron </li></ul></ul><ul><li>Presynaptic terminals have synaptic vesicles containing neurotransmitter chemicals </li></ul><ul><li>Neurotransmitters </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  13. 13. Components of a Synapse Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  14. 14. Reflexes <ul><li>Receive stimulus and generate response </li></ul><ul><ul><li>Unidirectional impulse conduction </li></ul></ul><ul><ul><ul><li>Sensory receptor </li></ul></ul></ul><ul><ul><ul><li>Sensory neuron </li></ul></ul></ul><ul><ul><ul><li>Interneurons </li></ul></ul></ul><ul><ul><ul><li>Motor neuron </li></ul></ul></ul><ul><ul><ul><li>Effector organ </li></ul></ul></ul><ul><li>Vary in complexity </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  15. 15. Neural Pathway Involved in Patellar (“Knee Jerk” ) Reflex Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  16. 16. Blood Supply <ul><li>Arterial blood supply to brain </li></ul><ul><ul><li>Vertebral arteries </li></ul></ul><ul><ul><li>Internal carotid arteries </li></ul></ul><ul><li>Circle of Willis </li></ul><ul><ul><li>Safeguard to ensure blood supply to all parts of the brain if vertebral or internal carotid arteries are blocked </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  17. 17. Blood Supply Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  18. 18. Veins <ul><li>Veins that drain blood from head form venous sinuses </li></ul><ul><li>Drain into internal jugular veins </li></ul><ul><li>Internal jugular veins join subclavian veins on each side of the body </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  19. 19. Venous Sinuses Associated with the Brain Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  20. 20. Ventricles of the Brain <ul><li>Lateral ventricle </li></ul><ul><li>Space in cerebral hemispheres is filled with cerebrospinal fluid </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  21. 21. Divisions of the Adult Brain <ul><li>Brain stem </li></ul><ul><ul><li>Medulla </li></ul></ul><ul><ul><li>Pons </li></ul></ul><ul><ul><li>Midbrain </li></ul></ul><ul><li>Cerebellum </li></ul><ul><li>Diencephalon </li></ul><ul><ul><li>Hypothalamus </li></ul></ul><ul><ul><li>Thalamus </li></ul></ul><ul><li>Cerebrum </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  22. 22. Neurological Pathophysiology <ul><li>Cerebral blood flow (CBF) interrupted by: </li></ul><ul><ul><li>Structural changes or damage </li></ul></ul><ul><ul><li>Circulatory changes </li></ul></ul><ul><ul><li>Alterations in intracranial pressure (ICP) </li></ul></ul><ul><li>Three structures in intracranial space: </li></ul><ul><ul><li>Brain tissue </li></ul></ul><ul><ul><li>Blood </li></ul></ul><ul><ul><li>Water </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  23. 23. Intracranial Space <ul><li>Brain tissue </li></ul><ul><ul><li>Mostly water, intracellular and extracellular </li></ul></ul><ul><li>Blood </li></ul><ul><ul><li>Major arteries in base of brain </li></ul></ul><ul><ul><li>Arterial branches, arterioles, capillaries, venules, veins within brain substance </li></ul></ul><ul><ul><li>Cortical veins and dural sinuses </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  24. 24. Intracranial Space <ul><li>Water in: </li></ul><ul><ul><li>Ventricles of brain </li></ul></ul><ul><ul><li>Cerebrospinal fluid </li></ul></ul><ul><ul><li>Extracellular and intracellular fluid </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  25. 25. Cerebral Perfusion Pressure (CPP) <ul><li>Cerebral blood flow depends on cerebral perfusion pressure </li></ul><ul><ul><li>Pressure gradient across brain </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  26. 26. Cerebral Blood Flow <ul><li>Cerebral blood flow controls oxygen and glucose delivery </li></ul><ul><ul><li>Cerebral perfusion pressure (CPP) and cerebral vascular bed resistance </li></ul></ul><ul><ul><li>CPP determined by: </li></ul></ul><ul><ul><ul><li>Mean arterial pressure (MAP): (Diastolic pressure + ⅓ pulse pressure) minus intracranial pressure </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  27. 27. Cerebral Blood Flow <ul><li>As ICP approaches MAP: </li></ul><ul><ul><li>Gradient for flow decreases </li></ul></ul><ul><ul><li>Cerebral blood flow restricted </li></ul></ul><ul><li>When ICP increases, CPP decreases </li></ul><ul><ul><li>As CPP decreases, cerebral vasodilation </li></ul></ul><ul><ul><li>Increases cerebral blood volume (increasing ICP) and further cerebral vasodilation </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  28. 28. ICP Review <ul><li>CBF (Cerebral Blood Flow) is a factor of CPP (Cerebral Perfusion Pressure) & CVR (Cerebral Vascular Resistance) </li></ul><ul><ul><li>If CPP  , then CBF  </li></ul></ul><ul><ul><li>If CVR  , then CBF most likely  </li></ul></ul><ul><li>CPP = MAP - ICP </li></ul><ul><ul><li>MAP = Diastolic + 1/3 PP </li></ul></ul><ul><ul><li>PP = SBP - DBP </li></ul></ul><ul><li>PCO 2 has greatest effect on CVR </li></ul><ul><ul><li>Sympathomimetics may  CVR </li></ul></ul>
  29. 29. ICP Review <ul><li>As PCO 2  , CVR  </li></ul><ul><ul><li>Therefore, if PCO 2  , CVR  </li></ul></ul><ul><ul><li>Then, as CVR  , CBF  </li></ul></ul><ul><li>Normal ICP < 15 mm Hg </li></ul><ul><li>As ICP  , CPP  then CBF  </li></ul><ul><li>Compensation for  ICP via  MAP </li></ul><ul><ul><li>Cushing’s Reflex (Triad) </li></ul></ul><ul><ul><li>Cushing’s triad with coma indicates possible herniation </li></ul></ul>
  30. 30. Is unconsciousness itself an immediate life threat? <ul><li>Loss of airway </li></ul><ul><li>Vomiting, aspiration </li></ul>YES, IT IS!
  31. 31. Altered Mental State Manage ABC’s Before Investigating Cause!
  32. 32. Goals of Emergency Care <ul><li>Airway control </li></ul><ul><li>Stabilization and support of cardiovascular system </li></ul><ul><li>Intervention to interrupt ongoing cerebral injury </li></ul><ul><li>Protection from further harm </li></ul><ul><li>Transport to an appropriate medical facility </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  33. 33. Initial Assessment <ul><li>Level of consciousness </li></ul><ul><li>Ensure patent airway </li></ul><ul><li>Immobilize cervical spine </li></ul><ul><li>Airway adjuncts if indicated </li></ul><ul><ul><li>Monitor for respiratory arrest </li></ul></ul><ul><li>Ventilatory support and supplemental oxygen for any neurological emergency </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  34. 34. Initial Assessment/Management <ul><li>Airway </li></ul><ul><ul><li>Open, clear, maintain </li></ul></ul><ul><ul><li>If trauma or + history, control C-spine </li></ul></ul><ul><li>Breathing </li></ul><ul><ul><li>Presence? Adequacy (rate, tidal volume)? </li></ul></ul><ul><ul><li>High concentration O 2 on ALL patients with altered mental status </li></ul></ul><ul><ul><li>Assist ventilations prn </li></ul></ul><ul><li>Circulation </li></ul><ul><ul><li>Pulses? Adequate Perfusion? </li></ul></ul>
  35. 35. History <ul><li>History of event from patient, family, bystanders </li></ul><ul><li>If loss of consciousness, ascertain events prior to unconscious state: </li></ul><ul><ul><li>Patient position (sitting, standing, lying down) </li></ul></ul><ul><ul><li>Complaints of a headache </li></ul></ul><ul><ul><li>Seizure activity </li></ul></ul><ul><ul><li>Fall </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  36. 36. History <ul><li>When no history is available, assume the onset of unconsciousness was acute and that an intracranial hemorrhage is likely </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  37. 37. Investigate Cause <ul><li>DERM </li></ul><ul><ul><li>D = Depth of Coma </li></ul></ul><ul><ul><li>E = Eyes </li></ul></ul><ul><ul><li>R = Respiratory Pattern </li></ul></ul><ul><ul><li>M = Motor Function </li></ul></ul>
  38. 38. D = Depth of Coma <ul><li>What does patient respond to? </li></ul><ul><li>How does he respond? </li></ul>Avoid use of non-specific terms like “stuporous”, “semi-conscious”, “lethargic”, “obtunded”
  39. 39. D = Depth of Coma <ul><li>AVPU </li></ul><ul><li>Glasgow Scale (later) </li></ul>Describe level of consciousness in terms of reproducible findings
  40. 40. Neurological Evaluation <ul><li>AVPU and Glasgow Coma Scale </li></ul><ul><ul><li>Determine baseline neurological status </li></ul></ul><ul><ul><li>Allow comparisons </li></ul></ul><ul><li>Report and record patient information with specific descriptive terms </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  41. 41. E = Eyes <ul><li>Pupils </li></ul><ul><ul><li>Size - mid, dilated or constricted </li></ul></ul><ul><ul><ul><li>measurement - e.g. 4 mm </li></ul></ul></ul><ul><ul><li>Shape - round, oval, pontine </li></ul></ul><ul><ul><li>Equality - equal in size </li></ul></ul><ul><ul><li>Symmetry - equal in reaction/response </li></ul></ul><ul><ul><li>Response to light </li></ul></ul><ul><ul><ul><li>Yes or No </li></ul></ul></ul><ul><ul><ul><li>How? </li></ul></ul></ul>
  42. 42. Pupils at Different Levels of Consciousness Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  43. 43. Extraocular Movements <ul><li>Conjugate gaze </li></ul><ul><ul><li>A deviation of both eyes to either side. </li></ul></ul><ul><ul><ul><li>Irritative focus </li></ul></ul></ul><ul><ul><ul><li>Destructive focus </li></ul></ul></ul><ul><li>Dysconjugate gaze </li></ul><ul><ul><li>Deviation of the eyes to opposite sides </li></ul></ul><ul><ul><ul><li>Brain Stem injury </li></ul></ul></ul>
  44. 44. R = Respiratory Pattern <ul><li>Depth </li></ul><ul><ul><li>Unusually deep or shallow? </li></ul></ul><ul><li>Pattern </li></ul><ul><ul><li>Regular or Unusual pattern </li></ul></ul><ul><ul><ul><li>Can you identify the pattern? </li></ul></ul></ul>
  45. 45. Respiratory Patterns <ul><li>Normal or abnormal </li></ul><ul><li>Abnormal respiratory patterns </li></ul><ul><ul><li>Cheyne-Stokes respiration </li></ul></ul><ul><ul><li>Central neurogenic hyperventilation </li></ul></ul><ul><ul><li>Ataxic respiration </li></ul></ul><ul><ul><li>Apneustic respiration </li></ul></ul><ul><ul><li>Diaphragmatic breathing </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  46. 46. Respiratory Patterns Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  47. 47. M = Motor Function <ul><li>Paralysis? </li></ul><ul><ul><li>Where? </li></ul></ul><ul><li>Muscle tone? </li></ul><ul><ul><li>Rigid or Flaccid </li></ul></ul><ul><li>Movement? </li></ul><ul><ul><li>Where? What is it like? </li></ul></ul><ul><li>Posturing? </li></ul><ul><ul><li>How? </li></ul></ul><ul><li>Symmetrical Motor Function? </li></ul>
  48. 48. Posturing, Muscle Tone, and Paralysis <ul><li>Disturbances of posture result from: </li></ul><ul><ul><li>Flexor spasms </li></ul></ul><ul><ul><li>Extensor spasms </li></ul></ul><ul><ul><li>Flaccidity </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  49. 49. Posturing, Muscle Tone, and Paralysis <ul><li>Decorticate rigidity </li></ul><ul><ul><li>Flexion </li></ul></ul><ul><ul><li>Abnormal flexor responses of one or both arms with extension of legs </li></ul></ul><ul><ul><li>Structural impairment of certain cortical regions of brain </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  50. 50. Posturing, Muscle Tone, and Paralysis <ul><li>Decerebrate rigidity </li></ul><ul><ul><li>Extension </li></ul></ul><ul><ul><li>Abnormal extensor response of arms and legs </li></ul></ul><ul><ul><li>Worse prognosis than decorticate rigidity </li></ul></ul><ul><ul><li>Impairment of subcortical regions of brain </li></ul></ul><ul><li>Flaccidity </li></ul><ul><ul><li>Brain stem or cord dysfunction </li></ul></ul><ul><ul><li>Dismal prognosis </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  51. 51. Posturing Abnormal extension (decerebrate posturing) Abnormal flexion (decorticate posturing) Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  52. 52. Assessment—Abnormal Reflexes <ul><li>Positive Babinski's sign </li></ul><ul><ul><li>Plantar reflex </li></ul></ul><ul><ul><li>Dorsiflexion of great toe with or without fanning of toes </li></ul></ul><ul><li>Relaxation of sphincter tone with evacuation of bowels and/or bladder </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  53. 53. Vital Signs <ul><li>Assess and record frequently </li></ul><ul><ul><li>May change rapidly </li></ul></ul><ul><ul><li>Monitor ECG for dysrhythmias </li></ul></ul><ul><li>Cushing’s triad, if increased ICP: </li></ul><ul><ul><li>Increase in systolic pressure (widening pulse pressure) </li></ul></ul><ul><ul><li>Decrease in pulse rate </li></ul></ul><ul><ul><li>Irregular respiratory pattern </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  54. 54. Physical Exam <ul><li>Vital Signs </li></ul><ul><ul><li>Shock? </li></ul></ul><ul><ul><li>Increased ICP? </li></ul></ul><ul><ul><li>Hypoxia/Hypercarbia </li></ul></ul><ul><li>Diagnostics </li></ul><ul><ul><li>Dysrhythmias? </li></ul></ul><ul><ul><li>Blood glucose </li></ul></ul><ul><ul><li>Oxygen saturation </li></ul></ul>
  55. 55. Physical Exam <ul><li>Detailed (Head-to-Toe) Exam </li></ul><ul><ul><li>Injuries causing coma? </li></ul></ul><ul><ul><li>Injuries caused by coma? </li></ul></ul><ul><ul><li>Clues to the cause </li></ul></ul>
  56. 56. Probable Causes of AMS <ul><li>Not enough Oxygen </li></ul><ul><li>Not enough Sugar </li></ul><ul><li>Not enough blood flow to deliver oxygen, sugar </li></ul><ul><li>Direct brain injury </li></ul><ul><ul><li>Structural </li></ul></ul><ul><ul><li>Metabolic </li></ul></ul>
  57. 57. Differentiating AMS Causes <ul><li>Structural </li></ul><ul><ul><li>Asymmetrical deficits </li></ul></ul><ul><ul><li>Unequal pupils </li></ul></ul><ul><ul><li>Afebrile </li></ul></ul><ul><ul><li>History of trauma, structural abnormality </li></ul></ul><ul><ul><li>Often a rapid onset </li></ul></ul><ul><li>Metabolic </li></ul><ul><ul><li>Symmetrical deficits </li></ul></ul><ul><ul><li>Equal pupils (? altered function) </li></ul></ul><ul><ul><li>? Fever </li></ul></ul><ul><ul><li>History of metabolic disorder or illness </li></ul></ul><ul><ul><li>Rapid onset less likely </li></ul></ul>
  58. 58. Management <ul><li>Maintain ABCs </li></ul><ul><li>Attempt to identify cause </li></ul><ul><li>Mainstays of therapy </li></ul><ul><ul><li>Oxygenation/Ventilation </li></ul></ul><ul><ul><li>IV fluids appropriate for the patient </li></ul></ul><ul><ul><li>D50 (if hypoglycemic) </li></ul></ul><ul><ul><li>Narcan if possibility of opiate OD </li></ul></ul><ul><ul><li>Flumazenil in known benzo only OD </li></ul></ul>
  59. 60. Coma <ul><li>A decreased state of consciousness from which a patient cannot be aroused </li></ul><ul><li>Mechanisms </li></ul><ul><ul><li>Structural lesions </li></ul></ul><ul><ul><li>Toxic Metabolic states </li></ul></ul><ul><ul><li>Psychiatric ‘mimicking’ </li></ul></ul>
  60. 61. Brain injury <ul><li>Recall that Brain injury is often shown by: </li></ul><ul><ul><li>Altered Mental Status </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Localizing signs </li></ul></ul>
  61. 62. Stroke and Intracranial Hemorrhage <ul><li>Stroke (“brain attack”) </li></ul><ul><li>Sudden interruption in brain blood flow </li></ul><ul><li>Results in neurological deficit </li></ul><ul><ul><li>Incidence </li></ul></ul><ul><ul><li>Morbidity/mortality </li></ul></ul><ul><ul><li>Risk factors </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  62. 63. Stroke Pathophysiology <ul><li>Blood supply to brain through four vessels </li></ul><ul><ul><li>Carotid arteries </li></ul></ul><ul><ul><ul><li>80% of cerebral blood flow </li></ul></ul></ul><ul><ul><li>Vertebral arteries </li></ul></ul><ul><ul><ul><li>Form basilar artery </li></ul></ul></ul><ul><ul><ul><li>20% of cerebral blood flow </li></ul></ul></ul><ul><ul><li>Interconnected at various levels </li></ul></ul><ul><ul><ul><li>Circle of Willis </li></ul></ul></ul><ul><li>Onset and symptoms depend on area of brain involved </li></ul>
  63. 64. Types of Stroke <ul><li>Neurological manifestations of decrease in blood flow to brain </li></ul><ul><li>Ischemic and hemorrhagic strokes </li></ul><ul><ul><li>Both can be life threatening </li></ul></ul><ul><ul><li>Ischemic stroke rarely causes death in first hour </li></ul></ul><ul><ul><li>Hemorrhagic stroke can be rapidly fatal </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  64. 65. Ischemic Stroke <ul><li>85% of strokes are ischemic </li></ul><ul><li>Cerebral thrombosis due to: </li></ul><ul><ul><li>Atherosclerotic plaques </li></ul></ul><ul><ul><li>Extrinsic pressure brain mass </li></ul></ul><ul><li>Thrombotic stroke </li></ul><ul><ul><li>Slower to develop than cerebral hemorrhage </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  65. 66. Cerebral Embolus <ul><li>Intracranial vessel occluded by foreign substance from outside CNS. </li></ul><ul><li>Signs and symptoms </li></ul><ul><ul><li>Similar to thrombotic stroke </li></ul></ul><ul><ul><li>Usually develop more quickly </li></ul></ul><ul><ul><li>Often have identifiable cause </li></ul></ul>
  66. 67. Hemorrhagic Stroke <ul><li>Incidence </li></ul><ul><li>Morbidity/mortality </li></ul><ul><li>Causes </li></ul><ul><ul><li>Cerebral aneurysms </li></ul></ul><ul><ul><li>Arteriovenous (AV) malformations </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><li>Signs and symptoms </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  67. 68. Transient Ischemic Attacks <ul><li>Focal cerebral dysfunction lasting from minutes to several hours </li></ul><ul><li>Return to normal < 24 hrs </li></ul><ul><li>No permanent neurological deficit </li></ul><ul><ul><li>Indication of impending stroke </li></ul></ul><ul><li>Signs and symptoms </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  68. 69. Differentiating between Ischemic and Hemorrhagic Stroke Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved. Ischemic Stroke Hemorrhagic Stroke Most common Least common Atherosclerosis or tumor within brain Cerebral aneurysms, AV malformations, hypertension Slow onset Abrupt onset Long history of vessel disease Stress or exertion Valvular heart disease and atrial fibrillation Cocaine and other sympathomimetic amines Hx of angina, previous strokes May be asymptomatic before rupture
  69. 70. Assessment <ul><li>Emergency care priorities </li></ul><ul><ul><li>Maintain patent airway </li></ul></ul><ul><ul><li>Provide adequate ventilatory support </li></ul></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Thorough history </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>Time in field must be reduced </li></ul></ul><ul><ul><li>Establish time of symptom onset (if possible) </li></ul></ul><ul><ul><li>Supportive measures </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  70. 71. Cincinnati Prehospital Stroke Scale <ul><li>A simple version of the National Institutes of Health Stroke Scale </li></ul><ul><li>Accurate in identifying patients with stroke </li></ul><ul><li>An abnormal finding in ANY of the three tests strongly suggests a stroke. </li></ul><ul><li>Facial Droop </li></ul><ul><li>Arm Drift </li></ul><ul><li>Slurred Speech </li></ul>
  71. 72. Los Angeles Prehospital Stroke Screen (LAPSS) <ul><li>Age </li></ul><ul><li>History </li></ul><ul><li>Symptom duration </li></ul><ul><li>Baseline disability </li></ul><ul><ul><li>Identifies asymmetry in: </li></ul></ul><ul><ul><ul><li>Facial smile/grimace </li></ul></ul></ul><ul><ul><ul><li>Grip </li></ul></ul></ul><ul><ul><ul><li>Arm strength </li></ul></ul></ul><ul><li>Asymmetry in any category indicates a possible stroke </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  72. 73. Prehospital Stroke Management <ul><li>Rapid transport </li></ul><ul><li>Determine time of symptom onset </li></ul><ul><li>Manage airway </li></ul><ul><li>Oxygen if SaO2 <92% </li></ul><ul><li>Monitor vital signs and ECG </li></ul><ul><li>Initiate IV en route </li></ul><ul><li>Assess blood glucose </li></ul><ul><li>Control seizures with benzodiazepines </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  73. 74. Seizure Disorders <ul><li>Temporary alteration in behavior or consciousness </li></ul><ul><li>Caused by abnormal electrical activity of neurons in brain </li></ul><ul><li>Incidence </li></ul><ul><li>Morbidity/mortality </li></ul><ul><li>Causes </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  74. 75. Types of Seizures <ul><li>All seizures pathological </li></ul><ul><ul><li>Arise from almost any region of brain </li></ul></ul><ul><ul><ul><li>Have many clinical manifestations </li></ul></ul></ul><ul><ul><li>Most common types </li></ul></ul><ul><ul><ul><li>Generalized </li></ul></ul></ul><ul><ul><ul><li>Partial (focal) </li></ul></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  75. 76. Generalized Seizures <ul><li>No definable origin (focus) in brain </li></ul><ul><li>May progress to generalized seizure </li></ul><ul><li>Petit mal (absence seizures) </li></ul><ul><li>Grand mal (tonic-clonic) seizures </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  76. 77. Petit Mal Seizures <ul><li>Often in children 4-12 y/o </li></ul><ul><li>Brief lapses of consciousness without loss of posture </li></ul><ul><li>Often no motor activity although may have: </li></ul><ul><ul><li>Eye blinking </li></ul></ul><ul><ul><li>Lip smacking </li></ul></ul><ul><ul><li>Isolated clonic activity </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  77. 78. Grand Mal Seizures <ul><li>Common </li></ul><ul><li>Associated with significant morbidity and mortality </li></ul><ul><li>May be preceded by an aura (olfactory or auditory sensation) </li></ul><ul><ul><li>Warning of imminent convulsion </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  78. 79. Grand Mal Seizure — Characteristics <ul><li>Sudden loss of consciousness with loss of organized muscle tone </li></ul><ul><ul><li>Tonic phase </li></ul></ul><ul><ul><li>Clonic phase </li></ul></ul><ul><ul><li>Postictal phase </li></ul></ul><ul><li>If prolonged or recur before patient regains consciousness: </li></ul><ul><ul><li>Status epilepticus </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  79. 80. Partial Seizures <ul><li>Arise from identifiable cortical lesions </li></ul><ul><li>Simple or complex </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  80. 81. Simple Partial Seizures <ul><li>Seizure activity in motor or sensory cortex </li></ul><ul><li>Simple motor seizures </li></ul><ul><li>Simple sensory seizures </li></ul><ul><li>Jacksonian seizure </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  81. 82. Complex Partial Seizures <ul><li>Focal seizures in temporal lobe (psychomotor) </li></ul><ul><li>Manifest as changes in behavior </li></ul><ul><li>Classic complex partial seizure </li></ul><ul><ul><li>Preceded by aura </li></ul></ul><ul><ul><li>Abnormal repetitive motor behavior </li></ul></ul><ul><ul><li>Typically less than 1 minute </li></ul></ul><ul><ul><li>Regains normal mental status quickly </li></ul></ul><ul><ul><li>May progress to tonic-clonic seizure </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  82. 83. Hysterical Seizures (Pseudoseizures) <ul><li>Mimic true seizure </li></ul><ul><li>Psychological causes </li></ul><ul><ul><li>Not considered true seizures </li></ul></ul><ul><ul><li>No organic origin </li></ul></ul><ul><ul><li>Do not respond to normal treatment </li></ul></ul><ul><li>Usually terminated by sharp commands or painful stimuli </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  83. 84. History and Physical Exam <ul><li>History of seizures </li></ul><ul><ul><li>Frequency </li></ul></ul><ul><ul><ul><li>Medication compliance </li></ul></ul></ul><ul><li>Description of seizure </li></ul><ul><ul><li>Duration </li></ul></ul><ul><ul><li>Pattern of seizure </li></ul></ul><ul><ul><li>Aura </li></ul></ul><ul><ul><li>Generalized or focal </li></ul></ul><ul><ul><li>Incontinence </li></ul></ul><ul><ul><li>Tongue biting </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  84. 85. History and Physical Exam <ul><li>History </li></ul><ul><ul><li>Recent or past history of head trauma </li></ul></ul><ul><ul><li>Recent history of fever, headache, nuchal rigidity </li></ul></ul><ul><ul><li>Significant past medical history </li></ul></ul><ul><li>Physical examination </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  85. 86. Syncope versus Seizure <ul><li>May be difficult to determine </li></ul><ul><ul><li>Differentiating characteristics are in symptoms before and after event </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  86. 87. Management <ul><li>Prevent physical injury </li></ul><ul><li>Oxygen via nonrebreather mask </li></ul><ul><li>Move away from onlookers </li></ul><ul><li>Transport for physician evaluation </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  87. 88. Status Epilepticus <ul><li>Seizure activity >30 min or recurrent seizure without intervening period of consciousness </li></ul><ul><li>Emergency </li></ul><ul><li>Causes </li></ul><ul><li>Associated complications </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  88. 89. Status Epilepticus Management <ul><li>Secure airway, ventilate, oxygenate </li></ul><ul><li>Protect from injury </li></ul><ul><li>Initiate IV </li></ul><ul><li>Benzodiazepines to control seizures </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  89. 90. Headache <ul><li>Categorized by underlying cause: </li></ul><ul><ul><li>Tension headaches </li></ul></ul><ul><ul><li>Migraines </li></ul></ul><ul><ul><li>Cluster headaches </li></ul></ul><ul><ul><li>Sinus headaches </li></ul></ul><ul><li>Common medical complaint </li></ul>
  90. 91. Tension Headaches <ul><li>Muscle contractions of face, neck, scalp </li></ul><ul><li>Causes </li></ul><ul><li>Signs and symptoms </li></ul><ul><li>Management </li></ul>
  91. 92. Migraines <ul><li>Severe, incapacitating headaches </li></ul><ul><li>Often preceded by visual or GI disturbances </li></ul><ul><li>Intense, throbbing pain on one side of head </li></ul><ul><ul><li>May spread </li></ul></ul><ul><ul><li>Often nausea and vomiting </li></ul></ul><ul><li>Constriction and dilation of blood vessels </li></ul><ul><ul><li>Imbalance of serotonin or hormone fluctuations </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  92. 93. Migraines <ul><li>Also triggered by: </li></ul><ul><ul><li>Excessive caffeine use </li></ul></ul><ul><ul><li>Various foods </li></ul></ul><ul><ul><li>Changes in altitude </li></ul></ul><ul><ul><li>Extremes of emotions </li></ul></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  93. 94. Cluster Headaches <ul><li>Occur in bursts (clusters) </li></ul><ul><li>Often several hours after asleep </li></ul><ul><li>Pain </li></ul><ul><ul><li>Severe </li></ul></ul><ul><ul><li>Usually around one eye </li></ul></ul><ul><ul><li>Often nasal congestion and tearing </li></ul></ul><ul><ul><li>Often lasts 30 min to 2 hrs, and recurs a day or so later </li></ul></ul><ul><ul><li>May occur every day for months before long periods of remission </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  94. 95. Cluster Headaches <ul><li>Histamine headaches </li></ul><ul><ul><li>Release of histamine from tissues </li></ul></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><ul><li>Dilated carotid arteries </li></ul></ul></ul><ul><ul><ul><li>Fluid accumulation under eyes </li></ul></ul></ul><ul><ul><ul><li>Tearing </li></ul></ul></ul><ul><ul><ul><li>Rhinorrhea </li></ul></ul></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  95. 96. Sinus Headaches <ul><li>Pain in forehead, nasal area, and eyes </li></ul><ul><li>Feeling of pressure behind face </li></ul><ul><li>Inflammation or infection of membranes lining sinus cavities or allergies </li></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  96. 97. Brain Neoplasm <ul><li>Mass in cranial cavity </li></ul><ul><li>Malignant or benign </li></ul><ul><li>Risk factors </li></ul><ul><li>Signs and symptoms </li></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  97. 98. Brain Abscess <ul><li>Accumulation of purulent material (pus) surrounded by a capsule within brain </li></ul><ul><li>Causes </li></ul><ul><li>Clinical manifestations </li></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  98. 99. Muscular Dystrophy <ul><li>Inherited muscle disorder </li></ul><ul><li>Unknown cause </li></ul><ul><li>Slow, progressive degeneration of muscle </li></ul><ul><li>Different forms classified by: </li></ul><ul><ul><li>Age symptoms appear </li></ul></ul><ul><ul><li>Rate of disease progression </li></ul></ul><ul><ul><li>How inherited </li></ul></ul><ul><li>Duchenne muscular dystrophy </li></ul><ul><ul><li>Most common type </li></ul></ul>
  99. 100. Muscular Dystrophy
  100. 101. Multiple Sclerosis (MS) <ul><li>Progressive CNS disease </li></ul><ul><li>Scattered patches of myelin in brain and spinal cord are destroyed </li></ul><ul><ul><li>Cause </li></ul></ul><ul><ul><li>Incidence </li></ul></ul><ul><ul><li>Morbidity/mortality </li></ul></ul><ul><ul><li>Clinical manifestations </li></ul></ul><ul><ul><li>Management </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  101. 102. Dystonia <ul><li>Local or diffuse alterations in muscle tone </li></ul><ul><ul><li>Usually abnormal muscle rigidity </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Painful muscle spasms </li></ul></ul><ul><ul><li>Unusually fixed postures </li></ul></ul><ul><ul><li>Strange movement patterns </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  102. 103. Dystonia <ul><li>Localized dystonia </li></ul><ul><ul><li>Torticollis (painful neck spasm) </li></ul></ul><ul><ul><li>Scoliosis (abnormal curvature of the spine) </li></ul></ul><ul><li>Generalized dystonia </li></ul><ul><ul><li>Parkinson disease </li></ul></ul><ul><ul><li>Stroke </li></ul></ul><ul><li>Also feature of schizophrenia or side effect of antipsychotic drugs </li></ul><ul><li>Management </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  103. 104. Parkinson Disease <ul><li>Degeneration or damage to nerve cells within basal ganglia in brain </li></ul><ul><li>Leading neurologic disability in persons over 60 yo </li></ul><ul><li>Characterized by : </li></ul><ul><ul><li>Muscle rigidity </li></ul></ul><ul><ul><li>Tremors (start on one side) </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><ul><li>Shuffling gait </li></ul></ul><ul><ul><li>May lead to dementia </li></ul></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  104. 105. Central Pain Syndrome <ul><li>Infection or disease of trigeminal nerve (cranial nerve V) </li></ul><ul><ul><li>Tic douloureux (trigeminal neuralgia) </li></ul></ul><ul><ul><ul><li>Common form </li></ul></ul></ul><ul><ul><ul><li>Excruciating pain </li></ul></ul></ul><ul><li>Affects one side of face </li></ul><ul><li>Brief attacks of intense pain </li></ul><ul><li>May be associated with MS in persons under 50 yo </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  105. 106. Bell’s Palsy (Facial Palsy) <ul><li>Paralysis of facial muscles </li></ul><ul><ul><li>Inflammation of seventh cranial nerve </li></ul></ul><ul><ul><li>Usually one sided and temporary </li></ul></ul><ul><ul><li>Often develops suddenly </li></ul></ul><ul><li>Affects 1 in 60 or 70 people </li></ul><ul><li>Often spontaneous recovery </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  106. 107. Bell’s Palsy Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  107. 108. Amyotrophic Lateral Sclerosis (ALS) <ul><li>Lou Gehrig’s disease </li></ul><ul><li>Rare disorders (motor neuron disease) </li></ul><ul><li>Nerves that control muscular activity degenerate within brain and spinal cord </li></ul><ul><li>Often begins with weakness in the arms and hands </li></ul><ul><li>Paralysis progresses to include respiratory muscles </li></ul><ul><li>Death often within 2-4 years of diagnosis </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  108. 109. Peripheral Neuropathy <ul><li>Diseases and disorders affecting peripheral nervous system, including: </li></ul><ul><ul><li>Spinal nerve roots </li></ul></ul><ul><ul><li>Cranial nerves </li></ul></ul><ul><ul><li>Peripheral nerves </li></ul></ul><ul><li>Damage or irritation of axons or myelin sheaths </li></ul><ul><li>Affect different areas of body </li></ul><ul><li>Many medical causes </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  109. 110. Myoclonus <ul><li>Rapid and uncontrollable muscular contractions (jerking) or spasms of muscle(s) </li></ul><ul><ul><li>Occur at rest or with movement </li></ul></ul><ul><li>Associated with: </li></ul><ul><ul><li>Disease of nerves and muscles </li></ul></ul><ul><ul><li>Brain disorder (e.g., encephalitis) </li></ul></ul><ul><ul><li>Seizure disorder </li></ul></ul><ul><li>May occur in healthy persons </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.
  110. 111. Spina Bifida <ul><li>Congenital defect </li></ul><ul><li>One or more vertebrae fail to develop completely </li></ul><ul><ul><li>Leaves portion of spinal cord exposed </li></ul></ul><ul><li>Most common in lower back </li></ul><ul><li>Incidence </li></ul><ul><li>Morbidity/mortality </li></ul><ul><li>Cause is unknown </li></ul>
  111. 112. Types of Spina Bifida <ul><li>Severity depends on how much nerve tissue is exposed after neural tube closure </li></ul><ul><ul><li>Spina bifida occult </li></ul></ul><ul><ul><li>Meningocele </li></ul></ul><ul><ul><li>Myelocele </li></ul></ul><ul><ul><li>Encephalocele </li></ul></ul>
  112. 113. Polio (Poliomyelitis) <ul><li>Caused by poliovirus hominis </li></ul><ul><li>Incidence declined in 1950s after vaccine </li></ul><ul><li>Risk if unvaccinated and traveling abroad </li></ul><ul><li>Febrile illness with or without paralysis </li></ul><ul><li>Can cause breathing difficulty </li></ul>Copyright © 2006, 2001, 1994 by Mosby, Inc. All rights reserved.

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