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  • 1. Chapter 31 NeurologyCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 2. Objectives Describe nervous system anatomy and physiology Outline pathophysiological changes in the nervous system that may alter cerebral perfusion pressure Describe assessment of patients with central nervous system disorders Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 3. Objectives Describe pathophysiology, signs and symptoms, and management techniques for:  Coma  Stroke  Headache  Seizure disorders  Brain neoplasm  Brain abscess  Degenerative disease  Intracranial bleeding Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 4. ScenarioYour patient is a 58-year-old man who awokewith drooping on the right side of his face andslurred speech. He has a history of seizuresand high blood pressure. He is very anxiousand crying as you begin your assessment andcare. Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 5. Discussion What additional assessments should you perform on this patient? List some possible causes of his facial drooping What is the significance of his medical history? Describe some interventions that you will consider for this man Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 6. Nervous System Anatomy Two parts  Central nervous system (CNS)  Peripheral nervous system (PNS) CNS  Brain  Spinal cord • Both encased in and protected by bone Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 7. Peripheral Nervous System 43 pairs of nerves originate from CNS to form PNS  12 pairs of cranial nerves • Originate from brain  31 pairs of spinal nerves • Originate from spinal cord Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 8. Cells of the Nervous System Neurons—fundamental units Neuroglia—connective tissue cells  Protect and hold neurons together Neurons  Cell body—single nucleus and nucleolus  Dendrites—branching projections  Axon—single, elongated projection Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 9. Cells of the Nervous SystemNeuron with dendrites, cell body, axon Segment of myelinated axon Neuron Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 10. Cells of the Nervous System Dendrites transmit impulses to neuron cell bodies Axons transmit impulses away from cell bodies  Bundles of parallel axons with sheaths are white • White matter Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 11. Cells of the Nervous System In PNS, bundles of axons and their sheaths are called nerves  Collections of nerve cells are gray • Gray matter  Gray matter is integration site within nervous system Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 12. Types of Neurons Classified by impulse transmission direction:  Sensory neurons  Motor neurons  Interneurons Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 13. Impulse Transmission Nervous system transmission similar to electrical impulse conduction in heart Unmyelinated axons Myelinated axons Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 14. Nerve Impulse ConductionUnmyelinated fiber Myelinated fiber Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 15. Synapse Membrane-to-membrane contact Separates axon endings of one neuron (presynaptic neuron) from dendrites of another neuron (postsynaptic neuron)  Presynaptic terminal  Synaptic cleft  Plasma membrane of postsynaptic neuron Presynaptic terminals have synaptic vesicles containing neurotransmitter chemicals Neurotransmitters Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 16. Components of a Synapse Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 17. Reflexes Receive stimulus and generate response  Unidirectional impulse conduction • Sensory receptor • Sensory neuron • Interneurons • Motor neuron • Effector organ Vary in complexity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 18. Neural Pathway Involved inPatellar (“Knee Jerk” ) Reflex Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 19. Blood Supply Arterial blood supply to brain  Vertebral arteries  Internal carotid arteries Circle of Willis  Safeguard to ensure blood supply to all parts of the brain if vertebral or internal carotid arteries are blocked Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 20. Blood SupplyCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 21. Veins Veins that drain blood from head form venous sinuses Drain into internal jugular veins Internal jugular veins join subclavian veins on each side of the body Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 22. Venous Sinuses Associated with the BrainCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 23. Ventricles of the Brain Lateral ventricle Space in cerebral hemispheres is filled with cerebrospinal fluid Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 24. Divisions of the Adult Brain Brain stem  Medulla  Pons  Midbrain Cerebellum Diencephalon  Hypothalamus  Thalamus Cerebrum Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 25. Neurological Pathophysiology Cerebral blood flow (CBF) interrupted by:  Structural changes or damage  Circulatory changes  Alterations in intracranial pressure (ICP) Three structures in intracranial space:  Brain tissue  Blood  Water Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 26. Intracranial Space Brain tissue  Mostly water, intracellular and extracellular Blood  Major arteries in base of brain  Arterial branches, arterioles, capillaries, venules, veins within brain substance  Cortical veins and dural sinuses Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 27. Intracranial Space Water in:  Ventricles of brain  Cerebrospinal fluid  Extracellular and intracellular fluid Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 28. Cerebral Perfusion Pressure (CPP) Cerebral blood flow depends on cerebral perfusion pressure  Pressure gradient across brain Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 29. Cerebral Blood Flow Cerebral blood flow controls oxygen and glucose delivery  Cerebral perfusion pressure (CPP) and cerebral vascular bed resistance  CPP determined by: • Mean arterial pressure (MAP): (Diastolic pressure + ⅓ pulse pressure) minus intracranial pressure Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 30. Cerebral Blood Flow As ICP approaches MAP:  Gradient for flow decreases  Cerebral blood flow restricted When ICP increases, CPP decreases  As CPP decreases, cerebral vasodilation  Increases cerebral blood volume (increasing ICP) and further cerebral vasodilation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 31. Goals of Emergency Care Airway control Stabilization and support of cardiovascular system Intervention to interrupt ongoing cerebral injury Protection from further harm Transport to an appropriate medical facility Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 32. Initial Assessment Level of consciousness Ensure patent airway Immobilize cervical spine Airway adjuncts if indicated  Monitor for respiratory arrest Ventilatory support and supplemental oxygen for any neurological emergency Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 33. Physical Examination Important elements  Patient history  History of event  Vital signs  Respiratory patterns Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 34. History History of event from patient, family, bystanders If loss of consciousness, ascertain events prior to unconscious state:  Patient position (sitting, standing, lying down)  Complaints of a headache  Seizure activity  Fall Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 35. History When no history is available, assume the onset of unconsciousness was acute and that an intracranial hemorrhage is likely Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 36. Vital Signs Assess and record frequently  May change rapidly  Monitor ECG for dysrhythmias Cushing’s triad, if increased ICP:  Increase in systolic pressure (widening pulse pressure)  Decrease in pulse rate  Irregular respiratory pattern Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 37. Respiratory Patterns Normal or abnormal Abnormal respiratory patterns  Cheyne-Stokes respiration  Central neurogenic hyperventilation  Ataxic respiration  Apneustic respiration  Diaphragmatic breathing Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 38. Respiratory PatternsCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 39. Neurological Evaluation AVPU and Glasgow Coma Scale  Determine baseline neurological status  Allow comparisons Report and record patient information with specific descriptive terms Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 40. Posturing, Muscle Tone, and Paralysis Disturbances of posture result from:  Flexor spasms  Extensor spasms  Flaccidity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 41. Posturing, Muscle Tone, and Paralysis Decorticate rigidity  Flexion  Abnormal flexor responses of one or both arms with extension of legs  Structural impairment of certain cortical regions of brain Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 42. Posturing, Muscle Tone, and Paralysis Decerebrate rigidity  Extension  Abnormal extensor response of arms and legs  Worse prognosis than decorticate rigidity  Impairment of subcortical regions of brain Flaccidity  Brain stem or cord dysfunction  Dismal prognosis Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 43. Posturing Abnormal flexion (decorticate posturing) Abnormal extension(decerebrate posturing) Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 44. Assessment—Abnormal Reflexes Positive Babinskis sign  Plantar reflex  Dorsiflexion of great toe with or without fanning of toes Relaxation of sphincter tone with evacuation of bowels and/or bladder Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 45. Pupils at DifferentLevels of ConsciousnessCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 46. Extraocular Movements Conjugate gaze Dysconjugate gaze Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 47. Conjugate GazeCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 48. Dysconjugate GazeCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 49. Coma Abnormally deep state of unconsciousness Cannot arouse by external stimuli Two mechanisms  Structural lesions  Toxic metabolic states Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 50. Coma Causes  AEIOU-TIPS Assessment Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 51. Stroke and Intracranial Hemorrhage  Stroke (“brain attack”)  Sudden interruption in brain blood flow  Results in neurological deficit  Incidence  Morbidity/mortality  Risk factors Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 52. Stroke Pathophysiology Blood supply to brain through four vessels  Carotid arteries • 80% of cerebral blood flow  Vertebral arteries • Form basilar artery • 20% of cerebral blood flow  Interconnected at various levels • Circle of Willis Onset and symptoms depend on area of brain involved Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 53. Types of Stroke Neurological manifestations of decrease in blood flow to brain Ischemic and hemorrhagic strokes  Both can be life threatening  Ischemic stroke rarely causes death in first hour  Hemorrhagic stroke can be rapidly fatal Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 54. Ischemic Stroke 85% of strokes are ischemic Cerebral thrombosis due to:  Atherosclerotic plaques  Extrinsic pressure brain mass Thrombotic stroke  Slower to develop than cerebral hemorrhage Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 55. Cerebral Embolus Intracranial vessel occluded by foreign substance from outside CNS Sources of cerebral emboli Signs and symptoms  Similar to thrombotic stroke  Usually develop more quickly  Often have identifiable cause Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 56. Hemorrhagic Stroke Incidence Morbidity/mortality Causes  Cerebral aneurysms  Arteriovenous (AV) malformations  Hypertension Signs and symptoms Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 57. Transient Ischemic Attacks Focal cerebral dysfunction lasting from minutes to several hours Return to normal <24 hrs No permanent neurological deficit  Indication of impending stroke Signs and symptoms Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 58. Differentiating between Ischemic and Hemorrhagic Stroke Ischemic Stroke Hemorrhagic StrokeMost common Least commonAtherosclerosis or tumor within Cerebral aneurysms, AVbrain malformations, hypertensionSlow onset Abrupt onsetLong history of vessel disease Stress or exertionValvular heart disease and atrial Cocaine and otherfibrillation sympathomimetic aminesHx of angina, previous strokes May be asymptomatic before rupture Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 59. Assessment Emergency care priorities  Maintain patent airway  Provide adequate ventilatory support  Oxygen  Thorough history Management  Time in field must be reduced  Establish time of symptom onset (if possible)  Supportive measures Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 60. Cincinnati Prehospital Stroke Scale Evaluates three physical findings:  Facial droop  Arm drift  Speech Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 61. Los Angeles Prehospital Stroke Screen (LAPSS) Age History Symptom duration Baseline disability  Identifies asymmetry in: • Facial smile/grimace • Grip • Arm strength Asymmetry in any category indicates a possible stroke Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 62. Prehospital Stroke Management Rapid transport Determine time of symptom onset Manage airway Oxygen if SaO2 <92% Monitor vital signs and ECG Initiate IV en route Assess blood glucose Control seizures with benzodiazepines Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 63. Seizure Disorders Temporary alteration in behavior or consciousness Caused by abnormal electrical activity of neurons in brain Incidence Morbidity/mortality Causes Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 64. Types of Seizures All seizures pathological  Arise from almost any region of brain • Have many clinical manifestations  Most common types • Generalized • Partial (focal) Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 65. Generalized Seizures No definable origin (focus) in brain May progress to generalized seizure Petit mal (absence seizures) Grand mal (tonic-clonic) seizures Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 66. Petit Mal Seizures Often in children 4-12 y/o Brief lapses of consciousness without loss of posture Often no motor activity although may have:  Eye blinking  Lip smacking  Isolated clonic activity Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 67. Grand Mal Seizures Common Associated with significant morbidity and mortality May be preceded by an aura (olfactory or auditory sensation)  Warning of imminent convulsion Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 68. Grand Mal Seizure—Characteristics Sudden loss of consciousness with loss of organized muscle tone  Tonic phase  Clonic phase  Postictal phase If prolonged or recur before patient regains consciousness:  Status epilepticus Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 69. Partial Seizures Arise from identifiable cortical lesions Simple or complex Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 70. Simple Partial Seizures Seizure activity in motor or sensory cortex Simple motor seizures Simple sensory seizures Jacksonian seizure Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 71. Complex Partial Seizures Focal seizures in temporal lobe (psychomotor) Manifest as changes in behavior Classic complex partial seizure  Preceded by aura  Abnormal repetitive motor behavior  Typically less than 1 minute  Regains normal mental status quickly  May progress to tonic-clonic seizure Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 72. Hysterical Seizures (Pseudoseizures) Mimic true seizure Psychological causes  Not considered true seizures  No organic origin  Do not respond to normal treatment Usually terminated by sharp commands or painful stimuli Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 73. History and Physical Exam History of seizures  Frequency • Medication compliance Description of seizure  Duration  Pattern of seizure  Aura  Generalized or focal  Incontinence  Tongue biting Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 74. History and Physical Exam History  Recent or past history of head trauma  Recent history of fever, headache, nuchal rigidity  Significant past medical history Physical examination Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 75. Syncope versus Seizure May be difficult to determine  Differentiating characteristics are in symptoms before and after event Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 76. Management Prevent physical injury Oxygen via nonrebreather mask Move away from onlookers Transport for physician evaluation Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 77. Status Epilepticus Seizure activity >30 min or recurrent seizure without intervening period of consciousness Emergency Causes Associated complications Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 78. Status Epilepticus Management Secure airway, ventilate, oxygenate Protect from injury Initiate IV Benzodiazepines to control seizures Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 79. Headache Categorized by underlying cause:  Tension headaches  Migraines  Cluster headaches  Sinus headaches Common medical complaint Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 80. Tension Headaches Muscle contractions of face, neck, scalp Causes Signs and symptoms Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 81. Migraines Severe, incapacitating headaches Often preceded by visual or GI disturbances Intense, throbbing pain on one side of head  May spread  Often nausea and vomiting Constriction and dilation of blood vessels  Imbalance of serotonin or hormone fluctuations Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 82. Migraines Also triggered by:  Excessive caffeine use  Various foods  Changes in altitude  Extremes of emotions Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 83. Cluster Headaches Occur in bursts (clusters) Often several hours after asleep Pain  Severe  Usually around one eye  Often nasal congestion and tearing  Often lasts 30 min to 2 hrs, and recurs a day or so later  May occur every day for months before long periods of remission Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 84. Cluster Headaches Histamine headaches  Release of histamine from tissues  Symptoms • Dilated carotid arteries • Fluid accumulation under eyes • Tearing • Rhinorrhea Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 85. Sinus Headaches Pain in forehead, nasal area, and eyes Feeling of pressure behind face Inflammation or infection of membranes lining sinus cavities or allergies Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 86. Brain Neoplasm Mass in cranial cavity Malignant or benign Risk factors Signs and symptoms Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 87. Brain Abscess Accumulation of purulent material (pus) surrounded by a capsule within brain Causes Clinical manifestations Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 88. Muscular Dystrophy Inherited muscle disorder Unknown cause Slow, progressive degeneration of muscle Different forms classified by:  Age symptoms appear  Rate of disease progression  How inherited Duchenne muscular dystrophy  Most common type Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 89. Multiple Sclerosis (MS) Progressive CNS disease Scattered patches of myelin in brain and spinal cord are destroyed  Cause  Incidence  Morbidity/mortality  Clinical manifestations  Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 90. Dystonia Local or diffuse alterations in muscle tone  Usually abnormal muscle rigidity Causes  Painful muscle spasms  Unusually fixed postures  Strange movement patterns Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 91. Dystonia Localized dystonia  Torticollis (painful neck spasm)  Scoliosis (abnormal curvature of the spine) Generalized dystonia  Parkinson disease  Stroke Also feature of schizophrenia or side effect of antipsychotic drugs Management Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 92. Parkinson Disease Degeneration or damage to nerve cells within basal ganglia in brain Leading neurologic disability in persons over 60 yo Characterized by :  Muscle rigidity  Tremors (start on one side)  Weakness  Shuffling gait  May lead to dementia Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 93. Central Pain Syndrome Infection or disease of trigeminal nerve (cranial nerve V)  Tic douloureux (trigeminal neuralgia) • Common form • Excruciating pain Affects one side of face Brief attacks of intense pain May be associated with MS in persons under 50 yo Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 94. Bell’s Palsy (Facial Palsy) Paralysis of facial muscles  Inflammation of seventh cranial nerve  Usually one sided and temporary  Often develops suddenly Affects 1 in 60 or 70 people Often spontaneous recovery Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 95. Bell’s PalsyCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 96. Amyotrophic Lateral Sclerosis (ALS) Lou Gehrig’s disease Rare disorders (motor neuron disease) Nerves that control muscular activity degenerate within brain and spinal cord Often begins with weakness in the arms and hands Paralysis progresses to include respiratory muscles Death often within 2-4 years of diagnosis Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 97. Peripheral Neuropathy Diseases and disorders affecting peripheral nervous system, including:  Spinal nerve roots  Cranial nerves  Peripheral nerves Damage or irritation of axons or myelin sheaths Affect different areas of body Many medical causes Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 98. Myoclonus Rapid and uncontrollable muscular contractions (jerking) or spasms of muscle(s)  Occur at rest or with movement Associated with:  Disease of nerves and muscles  Brain disorder (e.g., encephalitis)  Seizure disorder May occur in healthy persons Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 99. Spina Bifida Congenital defect One or more vertebrae fail to develop completely  Leaves portion of spinal cord exposed Most common in lower back Incidence Morbidity/mortality Cause is unknown Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 100. Types of Spina Bifida Severity depends on how much nerve tissue is exposed after neural tube closure  Spina bifida occult  Meningocele  Myelocele  Encephalocele Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 101. MeningoceleCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 102. MyelomeningoceleCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 103. Polio (Poliomyelitis) Caused by poliovirus hominis Incidence declined in 1950s after vaccine Risk if unvaccinated and traveling abroad Febrile illness with or without paralysis Can cause breathing difficulty Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 104. Conclusion Acute disorders of the nervous systemrequire rapid assessment and management. Paramedics can help reduce mortality andmorbidity, and produce maximal potential for rehabilitation and recovery. Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
  • 105. Questions?Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.