Alexander ch22 lecture

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Advanced EMT
A Clinical-Reasoning Approach, 2nd Edition
Chapter 22
Neurologic Disorders

• Applies fundamental knowledge to provide basic
and selected advanced emergency care and
transportation based on assessment findings for
an acutely ill patient.
Advanced EMT
Education Standard

1. Define key terms introduced in this chapter.
2. Recognize complaints that may indicate a neurologic
problem.
3. List possible underlying causes of neurologic
emergencies.
4. Explain the importance of airway assessment and
management in patients with altered mental status and
neurologic deficit.
5. Obtain a focused patient history for patients with a
neurologic emergency.
Objectives (1 of 6)

6. Given a scenario with a patient who has indications of a
neurologic emergency, perform a focused physical
examination.
7. Apply knowledge of the nervous system to patient
findings to identify more likely causes of the patient’s
condition.
8. Determine the need for emergency interventions in
the primary assessment of patients with a neurologic
emergency.
Objectives (2 of 6)

9. Identify the signs and symptoms of stroke.
10.Describe the pathophysiology of stroke.
11.Explain the importance of early recognition of stroke
signs and symptoms by patients, family or bystanders,
and EMS personnel.
12.Describe the relationship between stroke and transient
ischemic attack.
13.Assess the patient with possible stroke for neurologic
deficits, including use of a stroke assessment scale.
Objectives (3 of 6)

14.Discuss the role of blood glucose determination in the
assessment of patients with altered mental status,
neurologic deficits, and seizures.
15.Describe ways of communicating with patients who have
difficulty speaking.
16.Recognize indications that a headache may have a
potentially life-threatening underlying cause.
17.Describe measures that you can take to improve the
comfort level of the patient suffering from a headache.
Objectives (4 of 6)

18.Explain the importance of reassessing the patient who
is experiencing a neurologic emergency.
19.Describe the various ways that seizures can present.
20.Discuss possible underlying causes of seizures.
21.Explain the concerns associated with prolonged or
successive seizures.
22.Describe the assessment and emergency medical
care of patients who are having a seizure or are in a
postictal state.
Objectives (5 of 6)

23.Anticipate bystander reactions to patients having
seizures and measures needed to stop any unnecessary
or inappropriate interventions.
24.Compare and contrast features of dementia and delirium.
25.Describe basic information about various neurologic
disorders, such as Bell’s palsy, vertigo, Parkinson’s
disease, Wernicke-Korsakoff syndrome, multiple
sclerosis, normal pressure hydrocephalus, and others
that may affect the assessment and management of
patients.
Objectives (6 of 6)

• Neurologic disorders arise in either central or
peripheral divisions of the nervous system.
• Altered mental status, behavioral changes, and
neurologic deficits are common manifestations of
nervous system disorders.
Introduction (1 of 2)

• Understanding pathophysiology processes helps
you understand importance of your actions.
• Assessment and management
• Stroke, seizures, headaches, dementia, delirium,
selected chronic degenerative neurologic
diseases, infectious neurologic disorders,
nontraumatic back pain
Introduction (2 of 2)

Think About It
• What are some potential causes of the patient’s
headache?
• What level of concern should Anna and Brian
have for a chief complaint of severe headache?
• What is the best way to approach the gathering of
this patient’s history?
• What aspects of the examination will provide the
most important information?

Anatomy and Physiology Review
• Nervous and endocrine systems: two major
control systems of body
• Nervous system divisions
– Anatomically
 Central nervous system (CNS): brain, spinal cord
 Peripheral nervous system: all neural tissue outside brain
and spinal cord
– Functionally
 Somatic; voluntary
 Autonomic; involuntary

Table 22-1
Functions of the Sympathetic and Parasympathetic
Divisions of the Autonomic Nervous System
Sympathetic Parasympathetic
Alpha1 Receptors Beta1 Receptors Beta2 Receptors
Constriction of arterioles
and veins
Pupil dilation
Increase in heart
rate, strength of
contraction,
automaticity, and
conduction
Bronchodilation
Dilation of arterioles
Inhibition of uterine
contractions
Skeletal muscle tremors
Pupil constriction
Decrease in heart rate,
strength of contraction,
and blood pressure
Bronchoconstriction
Increase in
gastrointestinal tract
activity

Anatomy and Physiology
Review (1 of 4)
• Function of nervous system is to
– Monitor input from body’s environments
– Integrate sensory input
– Coordinate both voluntary and involuntary responses to
input

Figure 22-3
A representative neuron.

• Synapse
– Gap between axon and dendrites of adjacent neuron or
effector tissue
– Molecules of neurotransmitter secreted into synapse
and bind with receptors on dendrites
– Neurotransmitters secreted into synapse must be
broken down to prevent continuous stimulation.
Review (2 of 4)

Figure 22-5
Structure of the brain. (A) Superior view. (B) Sagittal view. (C) Frontal section view.

Table 22-2
Selected Neurotransmitters
Neurotransmitter Function
Acetylcholine Is the preganglionic neurotransmitter of the sympathetic nervous system and the pre-
and postganglionic neurotransmitter of the parasympathetic nervous system. Also
acts at the neuromuscular junction.
Dopamine Affects areas of the brain responsible for movement, emotions, and the ability to
experience pleasure. Dopamine regulation may play a role in addictions. Death of
dopamine-producing cells in a specific area of the brain results in Parkinson’s
disease. Some antipsychotics and antidepressants work by increasing
or decreasing dopamine activity in the brain.
Gamma-aminobutyric
acid (GABA)
Inhibits central nervous system activity. Deficiency can play a role in anxiety and
insomnia. Benzodiazepines, such as Valium and Xanax, work to decrease anxiety by
stimulating GABA receptors.
Glutamate Plays a role in learning and memory; may be deficient (or certain receptors for it may
be damaged) in Alzheimer’s disease and alcoholic brain damage.
Norepinephrine Helps regulate the reticular activating system. Excess in the amygdala and forebrain
can produce anxiety. Reduced norepinephrine activity may play a role in depression.
Some types of antidepressants prevent reuptake of norepinephrine.
Serotonin Regulates mood, emotion, appetite, and sleep. Responsible for general feelings of
well-being. Lack of serotonin in the brain may lead to depression. Many currently
used antidepressants selectively block the reuptake of serotonin in brain synapses.

• Human brain consists of six major parts
– Cerebrum
– Diencephalon
– Midbrain
– Pons
– Medulla oblongata
– Cerebellum
Review (3 of 4)

Table 22-3
Functions of the Brain
Brain Area Function
Frontal lobe Cognition, thinking, problem solving, reasoning, learning, judging, intelligence,
personality
Temporal lobe Hearing; verbal memory (left), visual memory (right)
Parietal lobe Touch, kinesthetic sense, balance, interpretation of sensory information, visuospatial
abilities, understanding spoken and written language.
Occipital lobe Receives and analyzes visual information
Cerebellum Maintains muscle tone, coordinates movement, helps maintain balance and posture
Medulla oblongata Regulates breathing and cardiovascular function; relays information between higher
brain centers and spinal cord to control skeletal muscle movement
Pons Relay center between higher brain centers and spinal cord, regulation of respiration
Reticular activating system
(RAS)
Nerve fibers within the hypothalamus, thalamus, medulla, pons, and midbrain
responsible for relaying sensory information from the spinal cord and maintaining
consciousness
Amygdala Part of the limbic system, plays roles in memory formation and emotional reactions
Thalamus Relay center between cortex and sense organs
Hypothalamus Controls hunger, thirst, temperature, aggression; interacts with pituitary gland for
integration of nervous and endocrine control

Review (4 of 4)
• Cerebrum uppermost portion of brain; responsible
for higher brain functions.
– Divided into right and left hemispheres
– Each hemisphere composed of frontal, temporal,
parietal, occipital lobes
– Higher brain function depends on integration and
coordination of many areas of the brain.

Assessment of Neurologic Complaints
• Presentation, complaints, and history help
determine if problem due to neurologic causes.
• May present with
– Altered mental status
– Behavioral changes
– Sensory impairment
– Headache
– Weakness
– Paralysis
– Other complaints

• Scene size-up
– Safety
– Number of patients
– Need for additional resources
– Nature of illness or mechanism of injury
– General appearance, mental status, chief complaint
Assessment of Neurologic
Complaints (1 of 10)

• Primary assessment
– Unresponsive patient
 Check carotid pulse; begin cardiac resuscitation.
– Determine level of responsiveness using AVPU.
– Patients with some neurologic problems can be deeply
unresponsive, leading to airway obstruction and
decreased ventilation.

• Primary assessment (continued)
– Establish and protect airway.
– Any patient with altered mental status with
compromised ABCs is critical and high priority.
– Impaired brain oxygenation worsens outcome of
neurologic problems.
– Limit secondary brain injury from poor perfusion,
hypoxia, hypoglycemia.

• Secondary assessment
– Obtain medical history; use mnemonics SAMPLE and
OPQRST.
– Obtain information from family if patient has altered
mental status
– Vitals, SpO2, blood glucose level, capnometry, and
cardiac monitoring per protocol

Table 22-4
Medications That May Indicate a Neurologic
Problem
Medication Use
amitriptyline (Elavil) Antidepressant, migraine
headaches, insomnia
carbamazepine (Tegretol) Seizures
chlorpromazine (Thorazine) Antipsychotic/neuroleptic
donepezil (Aricept) Alzheimer’s disease
gabapentin (Neurontin) Seizures, migraine headaches,
pain from neuropathies
haloperidol (Haldol) Antipsychotic/neuroleptic
L-DOPA/levodopa (Sinemet) Parkinson’s disease
lamotrigine (Lamictal) Seizures
meclizine (Antivert) Vertigo
phenytoin (Dilantin) Seizures
propranolol (Inderal) Migraine headaches
sumatriptan (Imitrex) Migraine headaches
valproic acid (Depakote) Seizures, migraine headaches

• Secondary assessment (continued)
– Consider possibility of increased intracranial
pressure (ICP) and concept of cerebral perfusion
pressure (CPP).
– Critical patient
 Perform rapid physical examination.
– Noncritical patient
 Perform focused physical examination.

• Secondary assessment (continued)
– Exams of mental and neurologic status required in
patients with potential neurologic problems.
– Examine pupils.
– Assess motor and sensory functions in all four
extremities.
– Use stroke screening tools.
– Determine Glasgow Coma Scale score.

Table 22-5
Cincinnati Prehospital Stroke Scale (CPSS)
Sign of Stroke Patient Activity Interpretation
Facial droop Have patient look up at you, smile,
and show his or her teeth.
Normal: Symmetry to both sides.
Abnormal: One side of the face droops or
does not move symmetrically.
Arm drift Have patient lift arms up and hold
them out with eyes closed for 10
seconds.
Normal: Symmetrical movement in both
arms.
Abnormal: One arm drifts down or
asymmetrical movement of the arms.
Abnormal speech Have patient say, “You can’t teach
an old dog new tricks.”
Normal: The correct words are used, and
no slurring of words is noted.
Abnormal: The words are slurred, the
wrong words are used, or the patient is
aphasic.
Source: Kothari, R. U., A. Pancioli, T. Liu, T. Brott, and J. Broderick. 1999. “Cincinnati Prehospital Stroke
Scale: Reproducibility and Validity.” Annals of Emergency Medicine 33, no. 4: 373-8.

Table 22-6
Los Angeles Prehospital Stroke Screen (LAPSS)
Considerations Yes Unknown No
Age greater than 45 years
No history of seizures or epilepsy
Duration of symptoms is less than 24 hours
Patient is not wheelchair bound or bedridden
Blood glucose level between 60 and 400 mg/dL
Physical exam to determine unilateral
asymmetry
Equal R Weakness L Weakness
A. Have patient look up, smile, and show teeth. Droop Droop
B. Compare grip strength of upper extremities. Weak grip Weak grip
No grip No grip
C. Assess arm strength for drift or weakness. Drifts down Drifts down
Falls rapidly Falls rapidly
Source: Kidwell, C.S., S. Starkman, M. Eckstein, K. Weems, and J. L. Saver. 2000. “Identifying Stroke in the Field:
Prospective Validation of the Los Angeles Prehospital Stroke Screen (LAPSS).” Stroke 31: 71-6.
doi:10.1161/01.STR.31.1.71

Table 22-7
Glasgow Coma Scale
Eye Opening
Spontaneous 4
To verbal command 3
To pain 2
No response 1
Verbal Response
Oriented and converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Motor Response
Obeys verbal commands 6
Localizes pain 5
Withdraws from pain (flexion) 4
Abnormal flexion in response to pain (decorticate rigidity) 3
Extension in response to pain (decerebrate rigidity) 2
No response 1

• Reasoning and decision making
– Understand basic functions of nervous system
and causes of neurologic signs and symptoms.
– Behavioral emergencies
– Headache
– Slurred speech

• Reasoning and decision making (continued)
– Extracranial
 Infection, metabolic problems, hypoxia, hypoperfusion,
toxins, environmental conditions, overdoses
– Intracranial
 Traumatic brain injury, stroke, epilepsy

Table 22-8
Mnemonic AEIOU-TIPS for Causes of Altered Mental
Status
A – Alcohol, anoxia
E – Environment, epilepsy
I – Insulin (diabetes and other endocrine disorders)
O – Overdose
U – Uremia (renal failure)
T – Trauma (shock, traumatic brain injury)
I – Infection
P – Psychosis, poisoning
S – Stroke

• Reasoning and decision making (continued)
– Manage airway, ventilation, oxygenation.
– Control bleeding and maintain blood pressure.
– Transport stroke or traumatic brain injury patient
to right facility for care.

• Reassessment
– Reassess critical patients every 5 minutes.
– Reassess noncritical patients every 15 minutes.
– Ask about changes in symptoms.
– Determine effects of any interventions.

• Altered mental status (AMS) not disease
in itself
– Indication of underlying problem affecting brain function
• Vulnerable due to decreased or lost reflexes
• Manage airway, breathing, circulation.
• Search for correctable underlying causes.
Altered Mental Status (1 of 2)

• AMS patients may have lost gag and cough
reflexes, muscle tone may be impaired, and
respirations may be depressed.
• If involvement of hypothalamus and brainstem,
may lose the ability to control body temperature,
blood pressure, heart rate, and respirations.
Altered Mental Status (2 of 2)

• Temporary loss of consciousness caused by
inadequate brain perfusion
• Neurologic symptoms precede loss of
consciousness
– Tunnel vision
– Loss of vision
– “Seeing stars”
– Ringing in the ears
Syncope (1 of 3)

• Causes
– Cardiac dysrhythmia
– Changes in components needed for adequate
blood pressure
– Medications that prevent increase in heart rate
or vasoconstriction
 Causes syncope when patient changes from supine or sitting
position to standing
– Vasovagal response
Syncope (2 of 3)

• Underlying cause in most cases is cardiovascular,
not neurologic.
• Syncope can be benign or it can have potentially
life-threatening causes.
• It is possible for patient to sustain injury if he falls
during the syncopal episode.
• Thoroughly evaluated and encouraged to be
transported to hospital
Syncope (3 of 3)

• Leading cause of death and disability
• Area of brain deprived of circulation and thus of
oxygen and glucose
• Ischemic stroke
– Blood clot blocks arterial blood flow to portion of brain
• Hemorrhagic stroke
– Rupture of blood vessel within cranium
Stroke

Figure 22-7
(A) (B)
Causes of stroke. (A) Blood is carried from the heart to the brain by way of the carotid and vertebral arteries,
which form a ring and branches within the brain. A hemorrhagic stroke occurs when a cerebral artery ruptures
and bleeds into the brain (examples shown: subarachnoid bleeding on the surface of the brain; intracerebral
bleeding within the brain). An ischemic stroke occurs when a thrombus is formed on the wall of an artery or
when an embolus travels from another area until it lodges in and blocks an arterial branch. (B) Brain tissues
distal to a rupture, thrombus, or embolus receive little or no perfusion and become ischemic (starved of oxygen)
and eventually infarcted (dead). When a thrombus grows slowly enough, collateral arteries may form parallel to
the blocked artery to perfuse or partially perfuse the oxygen-starved area of the brain.

• Stroke pathophysiology
– Ischemic stroke
 Often the result of atherosclerosis of cerebral arteries
or internal carotid arteries that supply blood to brain
– Risk factors for atherosclerosis are the same as those
for cardiovascular disease.
Stroke (1 of 7)

Table 22-9
Stroke Risk Factors
• Hypertension
• Diabetes
• Cardiovascular disease
• Prior stroke
• Transient ischemic attack
• Hypercholesterolemia
• Age > 55 years
• Gender (male)
• Ethnicity (African Americans and Hispanics have twice the risk as the population as a whole)
• Family history
• Hypercoagulative states (pregnancy, sickle cell disease, cancer)
• Smoking
• Obesity
• Atrial fibrillation
• Inactivity
• Cocaine, IV drug abuse
• Excessive alcohol use
• Hormonal contraceptives
• History of migraine headaches with an aura

Stroke (2 of 7)
• Stroke pathophysiology (continued)
– Hemorrhagic strokes occur due to rupture of
aneurysm in brain or from AVM.
– Hypertension and atherosclerosis risk factors
– Neurologic damage and death begin to occur
within 4 minutes.

Table 22-10
Stroke Terminology
Term Definition
Aphasia Difficulty with or loss of language skills; may be receptive (difficulty understanding
others) or expressive (difficulty expressing oneself); can include spoken or written
language
Ataxia Lack of coordination
Dysarthria Difficulty speaking due to weakness or paralysis of muscles involved in speech
Hemianopsia Loss of half the visual field
Hemiparesis Weakness on one side of the body
Hemiplegia Paralysis on one side of the body

• Stroke pathophysiology (continued)
– Transient ischemic attack (TIA)
 Temporary interruption in perfusion (from atherosclerotic
disease or emboli)
 Signs and symptoms resolve within one to two hours.
– Patient who has experienced TIA at high risk for
subsequent stroke
Stroke (3 of 7)

• Common warning signs of stroke
• Hemorrhagic often begin with sudden, severe
headache
– Unlike other headaches the patient has experienced,
followed by progressively worsening signs and
symptoms
• Ischemic stroke
– No headache; signs and symptoms at worst at or near
time of onset
Stroke (4 of 7)

• Stroke treatment
– Stroke chain of survival
– Recognize signs and symptoms that indicate stroke.
– Use prehospital stroke screening.
– Support ABCs.
– Oxygen to maintain SpO2 > 94%
– Establish time of onset.
– Transport to most appropriate facility.
Stroke (5 of 7)

• Stroke treatment (continued)
– IV en route.
– Prepare to manage seizures.
– Notify receiving facility.
– Check blood glucose.
Stroke (6 of 7)

Stroke (7 of 7)
• Stroke treatment (continued)
– Patients at risk for upper airway obstruction and
aspiration
– Treat hypoxia; do not overadminister oxygen.
– Patients may be hypertensive; not recommended
to treat high blood pressure in prehospital setting.
– For fibrinolytic treatment to be effective, must be
initiated within 3 to 4½ hours from onset of signs and
symptoms.

Table 22-11
General Inclusion and Exclusion Criteria for
Fibrinolytic Treatment
Inclusion Criteria Exclusion Criteria
• Ischemic stroke with measurable neurologic deficit • History of recent significant trauma, surgery, arterial
puncture, or gastrointestinal bleeding
• Onset of symptoms less than three hours before
treatment
• Active haemorrhage
• Suspected or known cerebral or intracranial bleeding;
previous
cerebral hemorrhage
• 18 years or older • Intracerebral tumor, aneurysm, or arteriovenous
malformation
• Disorders that cause delayed blood clotting and use of
some anticoagulant drugs, if labs are abnorma
• Low platelet count
• Hypertension (uncontrolled with medications)
• Pregnancy
• Minor or rapidly improving symptoms

Figure 22-9
A generalized tonic–clonic, or grand mal, seizure is a sign of abnormal release of
electrical impulses in the brain: (A) aura, (B) loss of consciousness followed by tonic phase,
(C) clonic phase, and (D) postictal phase.

Seizures (1 of 9)
• Abnormal discharge and spread of neuronal
activity through cerebral cortex, which interferes
with neurologic functioning
– Abnormal generalized motor activity
– Motor activity localized
– Behavioral change

Seizures (2 of 9)
• Underlying causes of seizures:
– Epilepsy
– Toxins, drugs
– Metabolic disorders
– Trauma
– Stroke
– Tumor
– Fever

Seizures (3 of 9)
• Key piece of information is whether or not patient
has history of seizures.
• Generalized seizures
– Tonic–clonic seizures: motor seizures involving entire
body; followed by postictal state
– Absence seizure: may appear as patient simply staring
off into space or daydreaming

Seizures (4 of 9)
• Partial seizures focal or localized to one area
of brain
– Simple partial seizures: motor, sensory, psychic,
autonomic phenomena
– Complex partial seizures: accompanied by aura;
involve impairment of awareness associated with
stereotyped movements and postictal period

Seizures (5 of 9)
• Patients may be injured during seizure, become
hypoxic or acidotic, or suffer airway obstruction
during postictal period.
• Postictal state
– May continue to be sleepy for several hours
following seizure
– May have copious oral secretions

Seizures (6 of 9)
• Administer oxygen.
• Control major bleeding.
• Assess for injuries and other abnormalities.
• Obtain vital signs and blood glucose level.
• Determine history; check for medical ID.
• IV if protocol permits.

Seizures (7 of 9)
• Status epilepticus
– Tonic–clonic seizure lasting more than 5 minutes, or
consecutive seizures without intervening period of
consciousness
– Life-threatening emergency

Seizures (8 of 9)
• Status epilepticus (continued)
– Request advanced life support, if available; transport
without delay.
– Manage patient’s airway and ventilation.
– Consult medical direction about fluid administration.

Seizures (9 of 9)
• Sudden Unexpected Death in Epilepsy (SUDEP)
– Does not occur during seizure; may occur shortly
afterward
– May be unwitnessed
– Autopsy findings are varied.

Think About It
• What have the findings so far suggested about
causes that should be higher on Brian and Anna’s
list of possible differential diagnoses?
• What line of questioning should Brian pursue
next?
• How should Brian and Anna approach treatment
and transport decisions for this patient?

Headache (1 of 9)
• Chief complaint; determine change in pattern
from patient’s other headaches
– Primary headache syndromes
 Migraines, cluster headaches, tension headaches
– Secondary headache syndromes
 Caused by other problems, some can be life threatening

Headache (2 of 9)
• Primary headache syndromes—migraine
– Abnormal nervous system pain transmission;
neurochemical in origin
– Occur more frequently in females than males
– Occur at younger age

Headache (3 of 9)
• Primary headache syndromes—migraine
(continued)
– Last from minutes to hours
– May experience aura prior to onset
– Pain accompanied by photosensitivity, nausea,
vomiting

Headache (4 of 9)
• Primary headache syndromes—cluster
– Uncommon; occur more frequently in males
– Sudden onset of series of severe headaches of short
duration
– Unilateral, temporal region or around eye

Headache (5 of 9)
• Primary headache syndromes—tension
– Dull, nagging pain; may extend from shoulders and
neck to scalp
– Abnormal serotonin or neurotransmitter activity

Headache (6 of 9)
• Secondary headache syndromes
– Vascular problems
– CNS or non-CNS infections
– Glaucoma
– Hypoxia
– Toxins
– High altitude
– Tumors
– Hypertension

Headache (7 of 9)
• Secondary headache syndromes (continued)
– Hypoglycemia
– Carbon monoxide exposure
– Fever
– Dental problems
– Preeclampsia
– Hypertension

Headache (8 of 9)
• Secondary headache syndromes—subarachnoid
hemorrhage
– Bleeding accumulates between brain and arachnoid
layer of meninges
– Sudden onset of severe headache; nausea, vomiting,
altered mental status
– May have meningismus, neck stiffness, and
photophobia

Headache (9 of 9)
• Secondary headache syndromes—subarachnoid
hemorrhage (continued)
– 50% of patients have normal vital signs, normal level of
responsiveness, no neck pain or stiffness.
– May result in death or disability.

Dementia and Delirium (1 of 6)
• Dementia
– Progressive condition in which intellectual function
severely impaired; may be accompanied by emotional
and behavioral changes.
– Intellectual components: impaired memory; reasoning;
and problem-solving, language, other cognitive skills

• Dementia (continued)
– Incidence increases with age; not normal consequence
of aging.
– Pathological causes
 Alzheimer’s disease
 Multi-infarct dementia
 Frontotemporal dementia

• Alzheimer’s
• Multi-infarct dementia
• Frontotemporal dementia

• Dementia
– Be calm and tolerant.
– World can be frightening place to patient.
– Such patients can be agitated and combative; behavior
arises from confusion.
– Ask caregivers if there has been sudden change in
mental status.

• Delirium
– Acute state of confusion that occurs from underlying
problem:
 Infection, metabolic disturbances, toxins, medications
– May have delusions and hallucinations; may be
frightened
– Protect patient from harm and reassure him.

• Excited delirium (ExDS)
– Delirium accompanied by agitated, combative behavior,
often prompting involvement of law enforcement
 Associated with cocaine, methamphetamine use
 Implicated in several deaths of persons in custody of law
enforcement

Vertigo
• Vertigo
– Subjective sensation of movement when there is none;
dizziness
– Nausea, vomiting, abnormal eye movements
– Precipitated by sudden movement of head

Nontraumatic Back and Neck Pain
• Impingement of spinal nerves; due to herniation
or rupture of intervertebral disc
– Weakness, numbness, tingling, pain along distribution
of nerve
– Spinal immobilization not indicated; may worsen
patient’s pain
– Consider serious medical conditions and potentially
life-threatening causes.

Central Nervous System Infections
• Encephalitis, meningitis, brain abscess all produce
neurologic signs and symptoms.
– Encephalitis
 Inflammation of brain by viral infection
– Meningitis
 Either viral or bacterial
– Brain abscess
 Focal, or localized, bacterial or fungal infection in brain

Other Neurologic Disorders (1 of 9)
• Bell’s palsy
– Temporary weakness or paralysis of facial nerve
– Drooping of affected side, drooling, loss of sense of
taste, numbness on affected side, dry eye or excessive
tearing
– Forehead generally involved only
– Majority of cases resolve in several weeks

• Normal pressure hydrocephalus (NPH)
– CSF produced within ventricles of brain cannot be
properly reabsorbed or drained; collects in abnormal
amounts
– Characterized by ataxia, dementia, urinary
incontinence
– Shunt may be placed to drain excess fluid.

• Parkinson’s disease
– Patients over age of 50; can occur earlier
– Loss of dopamine-producing cells in brain, resulting in
movement disorder
– Signs and symptoms: tremors, muscle rigidity, slowed
movements, problems with balance and coordination
– Disease is progressive.

• Multiple sclerosis
– Autoimmune disease; myelin sheath of nerves
destroyed; problems with nerve conduction
– Onset of disease between ages of 20 and 40
– Initial symptom is difficulty with vision.
– Muscle weakness (may progress to paralysis), tingling
sensations, and frequently cognitive symptoms

• Myasthenia gravis
– Autoimmune condition; acetylcholine receptors in
skeletal system blocked or destroyed
– Muscle weakness during activity; improves with rest
– Facial and respiratory muscles often affected
– Myasthenic crisis:
 Patient does not receive adequate amount of medication.
– Cholinergic crisis:
 Patient is overmedicated.

• Peripheral neuropathy
– Disorders of nerves of peripheral nervous system
– Patients with diabetes are especially prone.
– May be autoimmune; result of injury; or due to toxins,
infection, malnutrition.
– Signs and symptoms: pain, burning sensations,
numbness, tingling, weakness, wasting of affected
muscle groups

• Tardive dyskinesia: permanent side effect of taking
certain classes of medications, often
antipsychotics
– Repetitive, involuntary, purposeless movements
– Grimacing, blinking eyes, tongue protrusion, smacking
or puckering lips

• Acute dystonic reaction: temporary side effect of
taking types of medications implicated in tardive
dyskinesia
– Seen often in patients who have used illegal drugs
– Onset within hours or days
– Sudden onset of sustained or intermittent involuntary
muscle contractions
– Reaction frightening and confusing for patient

• Wernicke-Korsakoff syndrome
– Spectrum of degenerative neurologic disorders;
Wernicke’s encephalopathy and Korsakoff’s amnesic
syndrome
– Common in alcoholics, those with eating disorders, and
patients who are malnourished.
– Wernicke’s encephalopathy acute phase of disorder

Chapter Summary (1 of 5)
• Neurologic emergencies signs and symptoms
– Weakness
– Fatigue

• Complaints and signs that indicate neurologic
problem may be caused by other problems.
• Patient’s presentation, medical history, and list of
medications help to focus investigation.
• Know function of nervous system and
pathophysiology of neurologic disorders.

• Goals for managing patients with suspected
neurologic problems
– Manage airway, breathing, circulation.
– Look for immediately correctable causes of problem.
– Ensure open airway, adequate ventilation, and
oxygenation.

• Perfusion of brain may be affected by
– Dehydration
– Impairment of fluid regulation
– Decreased metabolism
– Cardiac dysrhythmia
• Administer fluids as needed.
• Hypoglycemia requires
– Oral or IV administration of glucose; OR
– IM administration of glucagon

• Altered mental status may be due to narcotic
overdose.
• With decreased respirations, consider
administering naloxone.
• Neurologic problems can be frightening and
frustrating for patients and families.
• Be empathetic and provide reassurance.

Alexander ch22 lecture

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